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UNITED STATES OF AMERICA. 



A TREATISE ON 

THE DISEASES OF THE 
NERVOUS SYSTEM 



WILLIAM A. HAMMOND, M. D. 

SURGEON-GENERAL U. S. ARMY (RETIRED LIST) ; LATE PROFESSOR OF DISEASES OF THE MIND AND 

NERVOUS SYSTEM IN THE COLLEGE OF PHYSICIANS AND SURGEONS OF NEW YORK, THE 

BELLEVUE HOSPITAL MEDICAL COLLEGE, THE UNIVERSITY OF THE CITY OF NEW YORK, 

AND THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL, ETC. 

WITH THE COLLABORATION OF 

GRJ1ME M. HAMMOND, M. D. 

PROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM IN THE NEW YORK POST-GRADUATE 

MEDICAL SCHOOL AND HOSPITAL ; FELLOW OF THE NEW YORK ACADEMY OF MEDICINE ; 

MEMBER OF THE NEW YORK NEUROLOGICAL SOCIETY ; OF THE 

AMERICAN NEUROLOGICAL ASSOCIATION, ETC. 






1 



WITH ONE HUNDRED AND EIGHTEEN ILLUSTRATIONS 



NINTH EDITION, WITH COEBECTIONS AND ADDITIONS 



Est quoddam prodire tenus, si non datur ultra."— Horace 



NEW YORK 

D. APPLETON AND COMPANY 

1891 



Copyright, 1876, 1881, 1886, 1891, 
By D. APPLETON AND COMPANY. 



PREFACE 



This, the ninth edition of my " Treatise on Diseases of the Nerv- 
ous System," has, with the assistance of my son, Dr. Gra3me M. Ham- 
mond, been thoroughly revised and brought up to the present time. 
The first edition of the work was published in 1871, and it has, there- 
fore, been for twenty years before the medical profession. During that 
time it has continued to receive approval both at home and abroad, 
and has been translated into the French, the Italian, and the Spanish 
languages. Several new chapters have been added to the present edi- 
tion, so that I may, I think, confidently express the opinion that it is 
more than ever worthy of the confidence which it has hitherto 
obtained. 

William A. Hammond. 

Washington, D. C, March 1, 1891. 



CONTENTS. 



PAGE 

Introduction, 17 

The Instruments and Apparatus employed in the Diagnosis and Treatment of 
Diseases of the Nervous System. 
Electrical Reactions, Normal and Pathological, . . . .28 



SECTION I. 

DISEASES OF THE BRAIN. 

CHAP. 

I. — Cerebral Congestion, 32 

Active Cerebral Congestion. — Passive Cerebral Congestion. 

II.— Cerebral Anaemia, 70 

III. — Cerebral Hemorrhage, . . .80 

IV. — Cerebral Meningeal Hemorrhage, 124 

Pachymeningitis and Hasmatoma of the Dura Mater. 
V. — Partial Cerebral Anemia from Obliteration of Cerebral 

Blood- Vessels, . . .132 

Thrombosis of Cerebral Arteries. — Embolism of Cerebral Arteries. — 
Thrombosis of Cerebral Veins and Sinuses. — Embolism and Thrombo- 
sis of the Cerebral Capillaries. 

VI. — Cerebral Softening, 161 

VII.— Aphasia, . . . . 182 

Vin.— Acute Cerebral Meningitis, 212 

IX. — Chronic Cerebral Menlngitis, 221 

Chronic Verticular Meningitis.- — Chronic Basilar Meningitis. 

X. — Tubercular Cerebral Meningitis, 251 

XI. — Suppurative Encephalitis or Cerebritis, .... 259 
Cerebria. 



10 CONTENTS. 

CHAP. PAGE 

XII. — Diffused Cerebral Sclerosis, 271 

XIII. — Paralysis Agitans, . 282 

XIV. — Tumors of the Brain, 200 

XV. — Athetosis, 315 

XVI. — Cerebral Syphilis, 342 

Anatomical Lesions. — Etiology. — General Symptomatology. 

XVII. — Symptomatology of Cerebral Lesions, 334 

Cortical Paralysis. — Paralysis consecutive to Central Lesions of the 
Hemispheres. — Lesions of the Tubercula Quadrigemina. — Oculo-Pu- 
pillary Troubles. — Lesions of the Optic Tracts. — Lesions of the Cere- 
bral and Cerebellar Peduncles. 
XV1IL— Symptomatology of Cerebellar Diseases, . . . .348 
Tumors of the Cerebellum. — Haemorrhages of the Cerebellum. — Noth- 
nagel's Diagnostic Points. 



SECTION II. 

DISEASES OF TEE SPINAL CORD. 

I. — Spinal Congestion, 365 

II. — Spinal Anemia, . . . . . . . . 373 

Aneemia of the Posterior Columns. — Anaemia of the Antero-Lateral Col- 
umns. 
III. — Spinal Haemorrhage — Spinal Meningeal Haemorrhage, . 406 

IV. — Spinal Meningitis, 413 

Acute Spinal Meningitis. — Chronic Spinal Meningitis. 
V. — The Inflammations of the Spinal Cord, . . . . 429 
Acute Myelitis. — Infantile Spinal Paralysis. — Spinal Paralysis of Adults. 
— Glosso-Labio-Laryngeal Paralysis. — Progressive Muscular Atrophy. 
— Progressive Facial Atrophy. — Tetanus. — Sclerosis of the Columns 
of Tiirck. — Primary Symmetrical Lateral Sclerosis. — Amyotrophic 
Lateral Spinal Sclerosis. — Progressive Locomotor Ataxia. — Sclerosis 
of the Columns of Goll. — Disseminated Inflammation of the Spinal 
Cord. — Secondai\y Inflammation and Degeneration of the Spinal Cord. 
VI. — Non -Inflammatory Softening of the Spinal Cord, . .611 

VTI. — Tumors of the Spinal Cord, 616 

VIII. — Syphilis of the Spinal Cord and its Membranes, . . 623 

IX. — Syringomyelia, 626 

X. — Pseudo-Hypertrophic Paralysis, 629 



CONTENTS. 11 

SECTION III. 

CEREBROSPINAL DISEASES. 
chap. PAGE 

I. — Hydrophobia, . . . . 641 

II.— Epilepsy, . . 663 

III. — Convulsive Tremor, • . ... 698 

IV:— Chorea, - 710 

V.— Hysteria, 727 

VI. — Hysteroid Affections, 742 

Catalepsy. — Ecstasy. — Hystero-Epiiepsy. 

VII.— Multiple Ceresro- Spinal Sclerosis, 770 

VIII.— Paretic Tremor, 782 

IX. — Anapeiratic Paralysis, . 784 

X. — Exophthalmic Goitre, .789 



SECTION IY. 

DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

I. — Neural Congestion, 804 

II. — Acute Neuritis, . . . 808 

III.— Sciatica, . . . . . 809 

IV. — Multiple Neuritis, . .815 

V. — Chronic Neuritis — Neural Sclerosis — Neural Atrophy, . 817 

VI. — Tumors of Nerves, 820 

VII. — Neural Paralysis, 821 

Facial Paralysis. — Paralysis of Third Nerve. 

VIII.— Neural Spasm, . . . ■ 831 

Facial Spasm. — Torticollis. 

IX. — Neural Anaesthesia, 834 

Anaesthesia of Cutaneous Nerves. — Aassthesia of the Fifth Pair. 

X. — Neural Hyperesthesia (Neuralgia), 838 

Neuralgia of the Fifth Pair of Nerves. — Cervico-Occipital Neuralgia. — 
Cervico - Brachial Neuralgia. — Dorso - Intercostal Neuralgia.— Lumbo- 
Abdorninal Neuralgia. — Crural Neuralgia. 
XI. — Syphilis of the Peripheral Nervous System, . . . 849 



12 CONTENTS. 

SECTION V. 

DISEASES OF THE SYMPATHETIC NERVOUS SYSTEM. 

CHAP. PAGE 

I. — Pathology of the Cervical Sympathetic, 851 

II. — Neuroses op the Cervical Sympathetic, 855 

Migraine, or Hemicrania. 

III. — Pathology of the Thoracic Sympathetic, 863 

IV. — Pathology of the Abdominal Sympathetic, . . . .865 

SECTION VI. 

CERTAIN OBSCURE DISEASES OF TEE NERVOUS SYSTEM. 

I. — Acute Ascending Paralysis (Landry's Paralysis), . . . 868 

II. — Myxcedema, 870 

III. — Acromegaly, . . . . 878 

IV.— Thomsen's Disease (Myotonia Congenita), 880 

V.— Raynaud's Disease (Symmetrical Gangrene of the Extremities), 882 

SECTION VII. 

TOXIC DISEASES OF THE NERVOUS SYSTEM. 

I. — Plumbism, 886 

II. — Alcoholism, 896 

III. — Bromism, 915 

I V. — Hydrargism, 921 

V. — Arsenicism, 923 



LIST OF ILLUSTRATIONS. 



FIG. 
1. 
2. 

3. 
4. 
5. 
6. 

Y. 



10. 
11. 

12. 

13. 
14. 

15. 
16. 

1Y. 

18. 

19. 

20. 
21. 
22. 
23. 

24. 



Static Electrical Machine, Hammond, 

MlLLIAMPEREMETER, " 

iEsTHESIOMETER, " 

Lombard's Differential Calorimeter, ... " 

Lombard's Thermo-Electric Pile, .... " 

Dynamometer, " 

Dcjchenne's Trocar, " 

Miliary Aneurism of Brain, Bouchard, 

" " " Hammond^ 

Atheromatous Artery of Brain, .... " 

Diagram explanatory of Paralysis in Cases of 

Cerebral Hemorrhage, " 

Diagram explanatory of Crossed Paralysis, . " 

Cerebral Arterial Thrombosis, . . . . Heubner, 

Cerebral Capillary Embolism, .... Virchow, 



PAGE 

. 20 
. 21 
. 23 

. 25 
. 26 

. 2Y 
. 28 
. 10Y 
. 10Y 
. 109 

. 113 
. 115 
. 140 
. 158 
. 158 



Diagram explanatory of the Cortical Lesions 

producing Aphasia, Modified from Naunyn, 204 

Agraphia, Hammond, . . . 208 

Dynamographic Tracing of Patient affected with 

Paralysis Agitans, " . . .286 

Dynamographic Tracing of Patient affected with 

Paralysis Agitans, " ... 28Y 

Malignant Tumor of Brain, Otis, . . . .301 

Aneurismal Tumor of Brain, .... Prof. W. R. Smith, . 308 

Hand of Patient with Athetosis, .... Hammond, . . . 31 Y 
" " after Photograph from Dr. Hub- 
bard, " ... 320 

Vertical Sections of the Brain, showing the Sit- 
uation of the Lesion in the Original Case of 

Athetosis, From drawings by Dr. 

Spitzka, . . .323 



14 



LIST OF ILLUSTRATIONS. 



FIG. 

25. 
26. 

27. 

28. 
29. 

30. 
31. 

32. 
33. 

34. 
35. 



38. 
39. 

40. 
41. 
42. 
43. 
44. 
45. 

46. 

47. 
48. 

49. 
50. 
51. 
52. 
53. 
54. 
55. 
56. 
57. 
58. 
59. 



Side View of the Human Brain and the Areas of 

the Cerebral Convolutions, . 
Horizontal Section through the Human Brain, 

showing the Internal Capsule, 
Diagram of the Relation of tiie Fields of Vision, 

Retina, and Optic Tracts, 

Diagram explanatory of the Crura Cerebri, 
Patient with Probable Atrophy and Sclerosis of 

Cerebellum, 

Diagram explanatory of the Medulla Oblongata, 
Morbid Anatomy in' Cervical Pachymeningitis, 
Deformity caused by Cervical Pachymeningitis, 
Deformity caused by Chronic Spinal Menin 



gitis, 

Spinal Cord in Infantile Spinal Paralysis, . 



Altered Nerve-Cells of Cord in Infantile Spinal 

Paralysis, 

Muscle in Infantile Spinal Paralysis, 



Atrophy of Muscles in Spinal Paralysis of 
Adults, 

Atrophy of Muscles in Spinal Paralysis of 
Adults, 

Glosso-Labio-Laryngeal Paralysis, 

Writing of Patient affected Tvrni Glosso Labio 
Laryngeal Paralysis, 

Glosso-Labio-Laryngeal Paralysis, 



<< u 



Progressive Muscular Atrophy, . 



Spinal Cord in Progressive Muscular Atrophy, 
Progressive Facial Atrophy, . . . . 
Progressive Facial Atrophy, .... 



Fcrricr, 



Hammond* 



. 337 



Gowers, . . .346 

Modified from Gowers, . 347 

Hafmmond, . . .379 
Modified from Edingcr, 359 
Joffroy, . . .418 

Charcot, 

Hammond, 
Charcot, 



Hammond, 



Duchenne, 

Friedreich, 

Duchenne, 

Charcot, 

Hammond, 

Lande, , 



. 419 

. 426 
. 447 
. 447 

. 448 

. 450 
. 451 
. 451 
. 451 
. 452 
. 452 
. 457 
. 457 

. 467 

. 477 
. 481 

. 483 
. 484 
. 485 
. 496 
. 498 
. 499 
. 501 
. 513 
. 522 
. 524 
. 524 
. 524 



LIST OF ILLUSTRATIONS. 15 

FIG. PAGE 

60. Muscular Fibre in Progressive Facial Atrophy 

(Longitudinal Section — normal), .... Hammond, . . . 528 

61. Muscular Fibre in Progressive Facial Atrophy 

(Longitudinal Section — abnormal), ... " ... 52S 

62. Muscular Tissue in Protressive Facial Atrophy 

(Transverse Section — normal), . " ... 528 

63. Muscular Tissue in Progressive Facial Atrophy 

(Transverse Section — abnormal), .... " ... 528 

64. Diagram of a Section of the Spinal Cord in the 

Cervical Region, Goioers, . . .532 

65. Diagram explanatory of Anaesthesia in Lesions 

of Cord, Hammond, . . .534 

66. Section of Spinal Cord in Sclerosis of Lateral 

Columns, . . Charcot, . . . 553 

67. Section of Spinal Cord in Lateral Sclerosis, " ... 553 

68. " " " " . ... 553 

69. Section of Medulla Oblongata, .... " ... 553 
TO. Diagram representing the connection between 

the Lateral Pyramidal Tract and the Motor 

Cells, Modified from Bramvxll, 554 

71. Deformity in Amyotrophic Lateral Spinal Scle- 

rosis, Charcot, . . . 558 

72. Section through Medulla Oblongata in Am to- 

trophic Lateral Spinal Sclerosis, ... " ... 563 

73. Writing of Patient with Locomotor Ataxia, . Hammond, . . . 572 

74. Dynamographic Tracing of Patient with Loco- 

motor Ataxia, " ... 573 

75. Dynamographic Tracing of Patient with Loco- 

motor Ataxia, " ... 573 

76. Superior Extremity of Healthy Humerus, . . Charcot, . . . 585 

77. " " Diseased Humerus of Pa- 
tient with Locomotor Ataxia, .... " ... 585 

78. Diagram explanatory of the Nerve-Fibres enter- 

ing the Cord, Modified from Edinger, 588 

79. Diagram explanatory of the Course of the Xerve- 

Fibres in the Spinal Cord, .... Edinger, . . . 589 

. 591 

. 596 

. 59S 

. 598 

. c98 

. 598 



80. Section of Spinal Cord in Locomotor Ataxia, . Pierret, 

81. Suspension Apparatus, . . . . . . Hammond, 

82. Sclerosis of Columns of Goll, .... Pierret, 

83. " " "...." 

84. " « " . « 



oO. " " . . . . " 

86. Diagram explanatory of the Connections between 

the Motor Tracts and the Motor Cells, . . Modified from Bramwell, 607 



16 



LIST OF ILLUSTRATIONS. 



FIG. 

87. 



Tumor of the Spinal Cord, 



90. 
91. 
92. 
93. 
9-1, 
95. 
96. 
97. 
98. 
99. 

100. 
101. 
102. 
103. 
104. 
105. 
106. 
107. 
108. 
109. 
110. 
111. 
112. 
113. 

114. 

115. 

116. 
117. 
118. 



Syringomyelia, 



Patient with Pseudo-IIypertrophic Paralysis 



Cortical Substance of Brain in Hydrophobia, 
Nuclei of Pneumogastric and Hypoglossal Nerves 
in Hydrophobia, ...... 

Root of Pneumogastric Nerve in Hydrophobia 
Neuroglia-Cells of Cord in Hydrophobia, . 
Contractions in Hysteria, .... 

Catalepsy (after Photograph from Dr. Early), 



Induced Catalepsy 

Ecstasy, 

Hystero-Epilepsy 



Writing of Patient with Multiple Cerebco 

Spinal Sclerosis, 

Writing of Patient with Anapeiratic Paral 

ysis, 

Exophthalmic Goitre (after Photograph from Dr 

J. B. Crawford), . . . 
Hand of Patient with Myxcedema, 
Portrait of Patient "w ith Myxcedema, . 
Diagram showing the Anatomical Divisions of 

the Spinal Cord, 





PAGE 


Charcot, 


. 618 


a 


. 618 


Leyden, 


. 621 


Van Giesen, . 


. 628 


<( 


. 628 


Hammond, 


. 632 


u 


. 632 


" 


. 634 


" 


. 635 


u 


. 635 


(( 


. 635 


a 


. 656 


a 


. 657 


u 


. 657 


a 


. 658 


Charcot, 


. 734 


u 


. 742 


Hammond, 


. 747 


u 


. 747 


u 


. 751 


Bourneville, . 


. 758 


Hammond^ 


. 764 


u 


. 765 


Charcot, 


. 767 


u 


. 768 


Bourneville, . 


. .769 


Hammond, 


. 780 


u 


. 786 


a 


. 792 


a 


. 875 


u 


. 876 



640 



DISEASES OF THE NERYOUS SYSTEM. 



INTRODUCTION. 

THE INSTRUMENTS AND APPARATUS EMPLOYED IN THE DIAGNOSIS 
AND TREATMENT OF DISEASES OF THE NERVOUS SYSTEM. 

Diseases of the nervous system, like those of the heart, lungs, 
and larynx, require special means of investigation and treatment. In 
no department of medical science has progress been more decided dur- 
ing the last decade than in that class of affections considered in this 
treatise, and undoubtedly a great deal of the advancement is due to 
the instruments and apparatus by which scientific research in this 
direction has become practicable. 

In the present chapter I propose to describe the instruments and 
apparatus employed in the diagnosis and treatment of diseases of the 
nervous system, and to explain the methods by which they are used. 

THE OPHTHALMOSCOPE. 

The ophthalmoscope consists essentially of a concave mirror per- 
forated in the centre, and of a double-convex lens. Several modifi- 
cations of this arrangement are in use, but the simplest instrument 
is, in my opinion, the best for ordinary use, and this is Liebreich's ; 
though, when very great exactness is required, as, for instance, in 
determining the depth of an atrophic excavation of the optic disk, 
Dr. Loring's ophthalmoscope is far preferable to any other. 

Liebreich's ophthalmoscope consists of a polished steel mirror about 
one and three-quarters inch in diameter, concave, and perforated in 
the centre by a hole about the one-twelfth of an inch in diameter. 
The edges of this aperture are beveled, so as to afford as little ob- 
stacle as possible to the passage of the rays of light to the eye of the 
observer. 

The mirror is set into a bronze ring with a handle, and there is 
attached also to this ring a clip for holding a concave ocular lens, 
which in some conditions of refraction, either in the eye of the pa- 
3 



18 DISEASES OF THE NERVOUS SYSTEM. 

tient or that of the observer, is necessary in order to produce the 
requisite divergence of the parallel rays emanating from the pa- 
tient's eye, and thus render the image of the fundus distinct. A 
direct image is thus obtained. The lamp, which should furnish a 
steady flame, is placed on the side of the patient's head correspond- 
ing to the eye to be examined, and the eye of the observer very 
close to that of the patient. This process gives a very satisfactory 
view of the fundus with the optic disk and retinal vessels, but re- 
quires care, and is more difficult than that by which the inverted image 
is obtained. 

In this case the observer illuminates the fundus with the ophthal- 
moscopic mirror, and then interposes between the mirror and the eye 
a double-convex lens which he holds lightly between the thumb and 
finger, resting the ring-finger on the forehead of the patient, so as to 
make the hand steady, the little finger being disengaged so as to be 
employed in raising the eyelid if necessary. 

The object-lens should have a focal distance of about two inches, 
and it should be held so as to bring the focus on the pupil. The lamp 
is placed behind and a little to one side of the eye to be examined. 
In order to see the optic disk, the patient is told to look at the ear of 
the observer on the side opposite to the eye being examined. In this 
way the axis of vision is directed inward, and the optic disk readily 
brought into view. 

These examinations are made in a room lighted only by the lamp 
used in the processes. It is sometimes necessary to dilate the pupil 
with atropia, in order to obtain a view of the disk, but experience and 
tact will generally enable the observer to dispense with this rather dis- 
agreeable procedure. 

Ophthalmoscopic examinations require the observer to possess a 
very thorough acquaintance with the anatomy of the eye, and also 
with the science of optics. Unless these qualifications are enjoyed, 
it will be much better to send the patient to a competent ophthalmic 
surgeon for an examination than to rush to hasty conclusions based on 
the most thorough ignorance. The real value of ophthalmoscopy in 
diseases of the nervous system is in danger of being disregarded 
through the sciolism of pert pretenders, who read papers and write 
memoirs without ever having seen the optic disk to recognize it. 

Bouchut 1 gives the following list of abnormal conditions which are 
of importance in the diagnosis of diseases of the nervous system : 

Papillary congestion ; peri-papillary congestion ; papillary anaemia, 
partial or general ; phlebo-retinal flexuosities ; venous pulsation in 
the retinal veins ; dilatations of the retinal veins ; retinal varices ; 
phlebo-retinal haemostases ; phlebo-retinal thromboses ; phlebo-retinal 

1 " Du diagnostic des maladies du systeme nerveux, par Tophtbalnioscopie," Paris, 
1866, p. 15. 



INTRODUCTION. 19 

aneurism ; haemorrhages into the retina and choroid. The diseases in 
which he thinks ophthalmoscopy is valuable as a diagnostic means 
are : The several varieties of cerebral meningitis ; cerebral haemor- 
rhage ; chronic encephalitis ; cerebral softening ; meningeal haemor- 
rhage ; chronic hydrocephalus ; tumors of the brain ; contusion, com- 
motion, and compression of the brain ; general paralysis ; atrophy of 
the brain ; chronic myelitis ; locomotor ataxia ; tetanus ; epilepsy ; 
essential convulsions ; insanity ; and several others of less importance. 
To these may be added cerebral congestion, general and partial; 
cerebral anaemia ; and the various forms of sclerosis affecting the brain 
and spinal cord. 

ELECTRICAL APPARATUS. 

The electrical apparatus required in the diagnosis and treatment 
of diseases of the nervous system must be of two kinds : one for 
furnishing the primary or galvanic current, the other for yield- 
ing the induced or faradaic current. Among the best machines of 
the first category are those in which the current is derived from 
the Leclanche, the Grenet, or the chloride-of-silver cells. If the Le- 
clanche elements are preferred, from forty to one hundred cells are 
necessary ; and as these cells are large, this form of battery can only 
be used as an office fixture. For a portable battery, those manu- 
factured by Waite and Bartlett, Jerome Kidder, the Galvano-Fara- 
dic Company, and the Barrett Battery Company, will be found to 
meet every requisite. The Barrett battery is especially adapted for 
transportation, as it contains no fluid. Portable batteries containing 
from twenty to thirty cells are strong enough for almost all prac- 
tical purposes. 

Of faradaic batteries, those manufactured by the firms previously 
mentioned leave nothing to be desired. Combination batteries, fur- 
nishing both galvanic and faradaic currents, can also be obtained from 
these makers. 

Lately there has been a revival of statical electricity, and such 
perfect instruments for its production are being manufactured that 
this form promises ere long to come into general use again. Fig. 1 
gives an excellent representation of the modern statical electric ma- 
chine. I have witnessed some excellent results of its therapeutical 
power in cases of neuralgia, paralysis, and rheumatism. 

Although the applications of electricity in the treatment of dis- 
eases of the nervous system are not so extensively useful as asserted 
by some authors, it is nevertheless impossible for the physician to 
treat several affections of the kind mentioned without using the agent 
in some form or other. This is especially true of those diseases which 
are characterized by paralysis, in nearly all of which electricity is use- 
ful. In atrophic disorders it is also indispensable, and in many hys- 



20 DISEASES OF THE NERVOUS SYSTEM. 

terical conditions it is extremely valuable. If only one battery can 
be procured, the faradaic instrument will be found more generally 
useful than any other ; but, if possible, the physician who intends to 




treat to the utmost advantage diseases of the nervous system, should 
possess one of all three kinds mentioned. 



THE MILLIAMPEREMETER. 

This instrument, a representation of which is given in Fig. 2, is 
used to determine the rate of the current flow, or the quantity of 
electricity which passes through that part of the individual which is 
included in the circuit of the galvanic current. The milliampere- 
meter is a galvanometer so constructed that the deflections of the 



INTRODUCTION. 



21 



Fig. 2. 



needle have definite meanings. Beneath the needle is a scale whose 
divisions represent milliamperes, or tenths of milliamperes. By means 
of resistance- 
coils, which can 
at pleasure be 
included in the 
circuit of the in- 
strument, each 
of the divisions 
can be made 
to represent re- 
spectively ten or 
onehundredm.il- 
iiamperes. The 
ampere is the 
unit of the cur- 
rent flow ; but 
as a current flow 
of one ampere 
is far too great 
for diagnostic 
or therapeutic 
purposes, and. as 
an individual 
could not en- 
dure a current 
of one ampere 
unless the elec- 
trodes were of 
enormous size, it 
has been found 
necessary to so 
regulate the re- 
sistance of the galvanometer that when a galvanic current is passed 
through it it will register thousandths of an ampere, or milliamperes. 

The milliamperemeter is as necessary to the physician who uses 
galvanism as the graduated measuring-glass is to the pharmacist. It 
enables him to measure accurately the quantity of electricity used. 
He can with certainty administer, day after day, the same flow of 
current, and by this means can definitely determine whether the same 
effects are always produced. 

When a current of a certain number of cells is applied to an indi- 
vidual, it can give no accurate idea of the flow of current through 
him. The resistance of individuals varies from day to day ; the re- 
sistance in the electrodes varies according to their degree of moist- 




•22 DISEASES OF THE NERVOUS SYSTEM. 

ure ; and the current derived from the battery-cells varies according 
to their condition of freshness. It can therefore be readily under- 
stood, as these three factors are never constant, how impossible it is 
to pass the same flow of current through the same tissues at any two 
consecutive trials. But if the milliamperemeter is included in the 
circuit, the differences in the resistance of the individual and the elec- 
trodes and the strength of the cells need not be considered. It is simply 
necessary to include as many cells in the circuit as may be required to 
deflect the needle of the meter to a certain point. At future trials, 
when the indicator reaches the same position, it signifies that the same 
flow of current is passing through the tissues, no matter whether it 
takes a greater or less number of cells to produce the desired result. 

CAUTERIZING APPARATUS. 

It is often necessary, in the treatment of diseases of the nervous 
system, to make use of the actual cautery to the spine and other parts 
of the body. The instruments formerly employed were very clumsy 
things made of iron, and, when required for use, were heated in a 
furnace of some kind. Lately the Paquelin cautery, furnished with 
platinum tips of such shapes as may be required, and the electric cau- 
tery, have come into general use. 

OTHER INSTRUMENTS AND APPARATUS. 

Among the other instruments and apparatus required in the diag- 
nosis and treatment of diseases of the nervous system are the micro- 
scope, the sphygmograph, the stethoscope, ear-specula, tuning-forks, 
urinary test apparatus and chemicals, hypodermic syringes, and a 
spray apparatus. The latter is useful for refrigerating the skin over 
the spinal column in cases of chorea and other affections. 

AESTHESIOMETER. 

The aesthesiometer is an instrument for the purpose of determining 
the degree of tactile sensibility possessed by the patient. It was de- 
vised in 1858 by Dr. Sieveking, 1 of London. Its' value in cases of 
aberrations of sensibility depends upon the fact, ascertained by Dr. E. 
H. Weber, that the capability of distinguishing two impressions, made 
upon the skin simultaneously, varies in different regions of the body 
according to the distance they are apart. In sensitive regions, as the 
end of the finger, the two points of a pair of dividers can be distin- 
guished at about the twelfth of an inch apart, while in the middle of 
the back only one point is felt, though they are two inches apart. In 
accordance with this principle, the aesthesiometer is used to determine 
the sensibility of the skin in various diseases, it being well known that 
this is subject to variation. 

1 British and Foreign Medico- Chirurgical Review, January, 1858, p. 281. 



INTRODUCTION. 



23 



Fig. 3. 



Thus, when the sensibility is intact, two points, touching the back 
of the hand at the same time, can be distinguished as two points when 
separated an inch. If, in examining a patient, we should find that, 
when the two points were two inches apart, the patient felt but a 
single impression, we should know that he had lost sensibility in the 
cutaneous nerves of that part of the body. 

Dr. Sieveking's sesthesiometer is nothing more than a beam-com- 
pass. It consists of a rod of bell-metal four inches in length, gradu- 
ated into inches and tenths of an inch. At one end is a fixed steel 
point ; another steel 
point is made to slide 
upon the beam, and 
can be fixed at any 
distance from the first 
by a screw which 
works at the top of 
the slide. 

In 1861 » I de- 
scribed an sesthesi- 
ometer which I be- 
lieve was the first used 
in this country. It 
consisted of a pair of 
dividers, to one arm 
of which the arc of a 
circle, in brass, was 
affixed. This arc was 
divided so as to meas- 
ure tenths of an inch. 
A short time since, 
I suggested to Mr. 

Stohlman, the instrument - maker, a modification of this instru- 
ment, which for convenience is, I think, superior to all others. This, 
as closed, for the pocket -case, and open, as in use, is seen in 
the accompanying woodcut (Fig. 3), 2 and need not be further de- 
scribed. 

The minimum normal distances at which the two points of the 
sesthesiometer can be distinguished in different regions of the body 
are stated in the table on the following page. 3 

1 "A Clinical Lecture on Chronic Myelitis," delivered in the Baltimore Infirmary, 
March 16, 1861, American, Medical Times, June 15, 1861, p. 379. 

2 First described by me in the Journal of Psychological Medicine, October, 1868, 
p. 830. 

3 This table is quoted from Muller's " Physiology," translated by Baly, London, 1840, 
P. 752. 




24 



DISEASES OF THE NERVOUS SYSTEM. 



Point of the tongue £ a line. 

Palmar surface of the third finger 1 " 

Red surface of the lips 2 lines. 

Palmar surface of second finger 2 

Dorsal surface of third finger 3 

Tip of the nose 3 

The palm over the heads of the metacarpal bones 3 

Dorsum of tongue, one inch from the tip 4 

Part of the lips covered by the skin 4 

Border of the tongue, an inch from the tip 4 

Metacarpal bone of the thumb 4 

Extremity of the great-toe 5 

Dorsal surface of the second finger 5 

Palm of the hand 5 

Skin of the cheek 5 

External surface of the eyelids 5 

Mucous membrane of the hard palate 6 

Skin over the anterior surface of the zygoma 7 

Plantar surface of the metatarsal surface of great-toe 7 

Dorsal surface of the first finger 7 

On the dorsum of the hand over the heads of the metacarpal 

bones 8 

Mucous membrane of the gums 9 

Skin over the posterior part of the zygoma 10 

Lower part of the forehead 10 

Lower part of the occiput 12 

Back of the hand 14 

Neck under the lower jaw 15 

Vertex 15 

Skin over the patella 16 

" " sacrum 18 

" " acromion 18 

The leg, near the knee and foot 18 

Dorsum of the foot, near the toes 18 

The skin over the sternum 20 

" " five upper vertebrae 24 

" " spine near the occiput 24 

" in the lumbar region 24 

" middle of the neck 30 

" over the middle of the back '. 30 

The middle of the arm , 30 

" " thigh 30 



THERMOMETER. 



The thermometer is of use for the purpose of determining varia- 
tions of temperature in different parts of the body. It should be 
graduated in tenths of a degree, and be held upon the part subject- 
ed to examination, so long as the mercury continues to rise or fall. 
Comparative determinations must be made under precisely similar 
conditions. 



INTRODUCTION. 



25 



Fig. 4. 



BECQUEREL S DISKS, 

By means of these little instruments very slight variations of tem- 
perature can be ascertained. They consist of an extremely thin plate 
of copper about the size of a half -dime, soldered to a thin rod of bis- 
muth. This latter is contained in a small tube of hard rubber fur- 
nished with a handle. The disks are two in number, and by means 
of delicate silk-covered wires are in communication with the poles 
of a galvanometer. If 
a lower extremity, for 
instance, is subjected to 
examination, one of the 
disks is placed upon it 
and the other upon the 
corresponding part of 
the other limb. If the 
temperature of both 
limbs be the same, the 
needle of the galvanom- 
eter remains quiet ; if 
either be warmer than 
the other, the needle is 
deflected to the north or 
south according as one 
or the other limb has 
the higher temperature. 
By this apparatus very 
much less than the hun- 
dredth of a degree of 
temperature can be de- 
termined with absolute 
accuracy 




1 See my " Memoir on the Pathology and Treatment of Organic Infantile Paralysis,'" 
in Journal of Psychological Medicine, No. 1, July, 1867, p. 53. 



26 



DISEASES OF TIIE NERVOUS SYSTEM. 



Fig. 5. 




DR. LOMBARD'S THERMO-ELECTRIC DIFFERENTIAL CALORIMETER. 

For determining differences of temperature nothing equals this 
instrument, both for exactness of results and facility of application. 
It consists, as shown in the accompanying cuts, of a galvanometer 
(Fig. 4) and two thermo-electric piles (Fig. 5). The needle of the 
galvanometer is astatic, and is suspended by a deli- 
cate silk fibre so as just to swing clear of the scale 
it is to traverse. Above the needle and outside of 
the glass shade is a magnet by means of w T hich the 
needle is readily made to point to the zero of the 
scale. 

Upon the ebonite plate to the left of the gal- 
vanometer needle are the bobbins and four little cups 
of mercury by means of which the connections are 
made, and the resistance of the thermo-electric cur- 
rent increased or diminished, according as it is neces- 
sary to make the needle more or less delicate in its 
indications. 

There are two thermo-electric piles, one of which 
is represented in Fig. 5, and which for convenience of 
manipulation are furnished with handles. These piles 
are connected by their positive and negative poles, 
and the other positive and negative poles are con- 
nected with the stanchions seen on the ebonite plate 
of the galvanometer. 

Having lowered the little metallic fork at the far- 
ther extremity of the bar over the ebonite plate into 
the cup of mercury immediately under it, the appa- 
ratus is ready for use. The delicacy is increased by 
lowering one or two, or all three of the others, each 
one being in connection with the bobbin immediately 
opposite to it, and which, when the fork is out of the 
mercury, is included in the circuit, and hence has the effect of in- 
creasing the resistance. In the figure all the forks are represented 
as down. 

To make an observation, the thermo-electric piles are placed one 
on the part the relative temperature of which it is desired to know, 
and the other on the corresponding sound part. If the pile in con- 
nection with the stanchion nearer the corner of the ebonite plate is in 
contact with the hotter part, the needle will be deflected to the north. 
If the other be the hotter, the needle will be deflected to the south. 
The extent of the deflection indicates the relative difference in hun- 
dredths of a degree centigrade. It is to be remembered that the 
instrument must be placed on a firm table or stand, and must be so 




INTRODUCTION. 27 

arrano-ed that the end of the scale to the right of the cut points to 
the north ; the ebonite plate will therefore be at the south end, and 
the galvanometer needle points to the east. 1 

With this apparatus of Dr. Lombard's it is easy to make relative 
determinations of temperature in a minute or two, and with great 
exactness and delicacy. 

Within the past year Waite and Bartlett have manufactured an 
instrument equally as delicate as Dr. Lombard's and much less com- 
plicated. 

THE DYXAMOIIETER. 

Several forms of an instrument for measuring the strength of pa- 
tients have been devised. The best and most generally applicable is 
that of M. Burq, modified by M. Mathieu, an instrument-maker of 
Paris, and still further modified by me. It is very simple, and for 
ascertaining the strength of the hands leaves nothing to be desired. 
It consists, as is shown in the cut (Fig. 6), of an elliptical steel spring, 
to one end of which is attached a semicircular metallic plate, upon 




which a scale is marked. An indicator, terminating at one end in a 
cog-wheel, is capable of being moved freely around the arc of the cir- 
cle by a steel arm, on one end of which a segment of a cog-wheel is 
attached, the cogs fitting into those of the indicator. The other end 
of the arm is fastened, by a bifurcated extremity, to both sides of the 
elliptical spring. 

When the dynamometer is taken into the hand and pressed, the 
two sides of the spring are approximated, and the steel arm with the 
cogs, being pushed by both sides of the spring, turns the indicator. 
When the pressure is relaxed the indicator returns to its original posi- 
tion. A second indicator, only attached to the plate by a spindle, is 
superimposed upon the first one and is earned around by it. This 
second indicator, not being connected with the spring, does not return 

1 For a fuller description of this instrument and directions for its use, the reader is 
referred to the British Medical Journal for 1875. 



28 DISEASES OF THE NERVOUS SYSTEM. 

to zero, but remains at the point to which it has been carried by the 
muscular power of the individual. We are thus enabled to see the 
extent of his strength, after he has made his effort, and do not have 
to watch him while he is using the instrument. In detecting the 
ability of the operator to maintain a steady muscular pressure this in- 
strument is also of service. Fluctuations of the indicator determine 
immediately whether the pressure on the spring is constant or not. 

duchenm's trocar. 

This very useful little instrument is shown in Fig. 7. It is intro- 
duced open as at a. When it has perforated the muscle under exam- 
ination, the small button at the under part of the handle is pushed 
forward ; this propels a half-cylinder of steel against the shoulder at 
the end of the trocar, and thus a small piece of muscle is detached 

Fig. 7. 




and caught in the cavity. The lower figure (b) represents the in- 
strument ready to be withdrawn. By drawing the button back, the 
bit of fibre can be taken out, and is then ready for microscopical 
examination. 



ELECTRICAL REACTIONS. 

NORMAL AND PATHOLOGICAL. 

In the diagnosis and treatment of diseases of ' the nervous system 
both the galvanic and faradaic currents are indispensable. 

In a normal condition of the muscular and nervous systems the 
muscles respond readily to moderate currents of both of these forms 
of electricity. If the faradaic current is used, the muscle or muscles 
to which the current is applied contract with every vibration of the 
interrupter. If the latter is so arranged as to make the interruptions 
slowly, there will be a distinct interval of rest between the contractions 
of the muscle. The more rapid the interruptions, the less interval 
there will be between the contractions of the muscle ; and, finally, if 
the vibrations of the hammer are extremely rapid, there will be no ap- 
preciable period of rest at all, and the muscle appears then to be in a 



ELECTRICAL REACTIONS. 29 

continuous state of rigid contraction. As the current of a faradaic 
battery is a " to-and-fro " current, running first in one direction and 
then in the other, it follows that normal muscular tissue must respond 
instantly to these rapid changes of current in order to continue in a 
constant state of rigidity. In many forms of paralysis this ability to 
respond to a rapidly vibrating current is lost. It is therefore advisa- 
ble, in procuring a faradaic battery, to obtain one which admits of both 
fine and coarse interruptions. If the galvanic current is used, it will be 
observed that the muscle to which it is applied only contracts at the 
"making" and at the "breaking" of the circuit, or when the strength 
of the current is suddenly changed. While the current is continuous 
the muscle remains quiescent. The same results are obtained whether 
the electrical applications are made to the nerves or to the muscles. 

The two poles of a battery are known as the anode or positive, and 
the cathode or negative. 

In testing the electrical reactions of a muscle, one electrode, the 
sponge surface of which should be at least two inches in diameter, 
should be placed on some indifferent part of the body, such as, for in- 
stance, the sternum, or the skin over some portion of the spine. The 
other electrode should be much smaller and must be provided with an 
"interrupting handle." This electrode is to be applied directly to the 
motor points of the muscles which are to be tested. By means of a 
" pole-changer " attached to the battery either electrode can be made 
cathode or anode at pleasure. 

In individuals in a normal state of health muscular contraction, 
under the stimulation of the galvanic current, follows definite laws. 

If the weakest current is employed that will cause a muscular con- 
traction, it is found to take place when the negative pole is applied to 
the muscle and the circuit is then closed. This is termed the cathodal 
closure contraction, and is designated by the letters C.C.C. or K.C.C 

If the current is increased in strength, the cathodal closure contrac- 
tion will be stronger,, and there will also be a slight contraction if the 
pole on the muscle is made the anode and the circuit is suddenly 
closed. This latter is known as the anodal closure contraction, and is 
represented by the letters A.C.C. With increased strength of current 
we are enabled to obtain the anodal opening contraction, A.O.C., and 
the cathodal opening contraction, C.O.C. or K.O.C. It will therefore 
be observed that in health the cathodal closure contraction is greater 
than the anodal closure contraction, and the anodal opening contrac- 
tion is greater than the cathodal opening contraction. 

The normal reactions, therefore, assuming that a sufficiently pow- 
erful current is employed, are as follows : 

1. C.C.C. 2. A.C.C. 3. A.O.C. 4. C.O.C. 

When degenerative changes occur in the motor nerves or in the 
motor cells in the anterior horn of gray matter in the spinal cord, the 



30 DISEASES OF THE NERVOUS SYSTEM. 

normal reactions both to faradism and to galvanism change materially. 
These changes have been termed the " reactions of degeneration " by 
Erb, who first described them. The reactions of the nerves and mus- 
cles differ, and must therefore be considered separately. 

When the motor nerves are the seat of a degenerative process the 
reaction of the nerve to both faradaic and to galvanic currents de- 
creases proportionately as the degeneration increases, and, if the dis- 
ease is not arrested, all excitability disappears in about two weeks* 
time. This is termed "quantitative degeneration." 

The muscular contractility also undergoes quantitative degenera- 
tion. The rapidly interrupted faradaic current fails to contract the 
muscles at all, but a slowly interrupted current will for a few days 
induce slight contractions. The reaction to the galvanic current also 
gradually decreases. 

At the end of about the first week " qualitative " degenerations can be 
obtained. It will then be observed that the cathodal closure contraction 
has either diminished considerably or else has disappeared altogether, 
while the anodal closure contraction, which was formerly insignificant, 
now takes precedence over all others. Frequently the cathodal and ano- 
dal opening contractions cannot be obtained at all, but if they can be it 
will be observed that the cathodal opening contraction is the stronger. 

Comparing the normal polar reactions with those obtained where 
disease of the motor nerve exists, we note the following difference : 
In health : 1. C.C.C. 2. A.C.C. 3. A.O.C. 4. C.O.C. 
In disease : 1. A.C.C. 2. C.C.C. 3. C.O.C. 4. A.O.C. 

Sometimes the polar degenerative reactions are not so well marked. 
In a few instances it will be observed that the anodal closure contrac- 
tion equals but does not excel the cathodal closure contraction. In 
that case the reactions are written as follows : 

A.C.C. == C.C.C. and C.O.C. = A.O.C. 

If the degeneration of the nerve advances till it is completely de- 
stroyed, the polar degenerative reactions gradually fail quantitatively 
and eventually disappear in the reverse order to that in which they 
are obtained. That is, the first to be lost will be the anodal opening 
contraction, then the cathodal opening contraction, then the cathodal 
closure contraction, and finally the anodal closure contraction. 

If the destruction of the nerve is not completed and if regenera- 
tion ensues, the electrical reactions gradually return to their normal 
condition. If a nerve has been so injured that it can not transmit vo- 
litional motor impulses, and even electrical excitation fails to induce 
muscular contractions, and then recovery takes place, it will be found 
that the muscles respond to the will some time before they will react 
to any form of electrical irritation. 

When the anterior horn of gray matter in the spinal cord is dis- 
eased so that the motor cells are involved, there is paralysis. 



ELECTRICAL REACTIONS. 31 

"Within three days after the paralysis appears it will be found that 
electrical excitation applied to the motor nerves which spring from 
the diseased area fails to produce strong muscular contractions, and 
that, as the disease progresses, the excitability of the nerve gradually 
diminishes to both forms of current till in about two weeks' time it 
is abolished altogether. 

The degenerative reactions observed in the muscular system must 
not be confused with those obtained by electrically exciting the nerve. 

The muscles which receive their motor energy from the diseased 
segment of the cord soon lose their contractility to the faradaic current. 
At first a slowly interrupted current will induce contractions, but at 
the end of two weeks from the beginning of the paralysis the strong- 
est current that the individual can bear is devoid of any motor effect. 
The galvanic excitability decreases slowly for a few days and then grad- 
ually increases until a slight current, which in the normal state would not 
induce any appreciable muscular movement, is observed to be followed 
by strong contractions. With this quantitative increase the qualitative 
polar reactions make their appearance in the same manner as when the 
nerve was the seat of disease. The cathodal closure contraction de- 
clines, the anodal closure contraction is augmented, and the cathodal 
opening contraction takes precedence over the anodal opening contrac- 
tion. As the disease advances and the muscles undergo atrophy there is 
the same quantitative decline in the contractions that is seen when the 
nerve is completely degenerated ; and, finally, when the contractile ele- 
ments of the muscles have been entirely absorbed no contractions can 
be obtained from any strength of current. As in cases of degeneration 
of the nerve, the anodal closure contraction is the last to disappear. 

W T hen paralysis follows from cerebral disease and there is no de- 
generation of the muscles, of the motor nerve supplying the muscles, 
or of that portion of the spinal cord from which the motor nerves 
arise, the electrical reactions will be found to be normal. 



SECTION L 
DISEASES OF THE BEAIK 



CHAPTER I. 

CEREBRAL CONGESTION. 



Cerebral congestion is of two kinds, which differ as regards their 
mode of origin and symptoms. In the active form, there is an increase 
in the amount of arterial blood circulating in the vessels of the brain ; 
in the passive, the quantity of venous blood is augmented. Occasion- 
ally the two conditions coexist. 

ACTIVE CEREBRAL CONGESTION. 

This is muqji the more common form. Of the cases recorded in 
my note-book, as occurring in my private and hospital practice, over 
five-sixths were of this description. 

Andral, who, however, failed to distinguish the first or hypersemic 
stage, recognized eight varieties, all of which may with advantage be 
comprehended in six, which are appropriately designated from the 
chief feature characterizing the attack, namely, the apoplectic, the par- 
alytic, the convulsive, the soporific, the maniacal, ,and the aphasic, the 
latter being a sixth form, which is now for the first time systematic- 
ally arranged in the present category. It will doubtless be the case 
that, as our knowledge of the functions of the brain becomes greater, 
other forms of cerebral congestion, especially those of a partial charac- 
ter — like the aphasic, for instance — will be recognized. Among these 
will be various sensory and motor disturbances, and perhaps also ab 
errations of mentality. For the present, however, it is perhaps better 
to defer considering these conditions, as often being instances of local- 
ized congestion, till the science of brain localization is more completely 
established. 

Any of these may occur with scarcely a moment's warning. Gen- 
erally, however, there is a premonitory or first stage, the symptoms of 



CEREBRAL CONGESTION. 33 

which, though well marked, are not peculiar, exclusively, to any one of 
the fully established conditions mentioned. It is therefore impossible 
to predict with accuracy, from the symptoms of this prodromatic stage, 
whether the apoplectic, the paralytic, the convulsive, the soporific, the 
maniacal, or the aphasic form, will be developed. An attentive study 
of this stage should always be made, and active measures taken for the 
relief of the patient at a time when success can generally be obtained. 

Symptoms. First Stage (Cerebral Hyper jemia). 

Among the earliest symptoms of active cerebral congestion, wake- 
fulness is especially noticeable, and may be for a time the only evidence 
of disorder which attracts the attention of the patient. He goes to 
bed feeling weary, and as if sleep would very quickly overtake him, 
but he is disappointed, for he obtains but an hour or two of disturbed 
slumber, which is generally broken by unpleasant dreams. During 
the remainder of the night he tosses restlessly from side to side of the 
bed, his mind either occupied by the thoughts which have occurred to 
him through the day, or else filled with the most preposterous ideas. 
He consequently rises unrefreshed, feverish, and ill prepared for either 
mental or physical exertion. 1 So far as the mind is concerned, there 
is an inability to give the attention to any subject requiring much 
thought, and at times an absolute want of power to get correct ideas 
of even simple matters. This is especially seen in those who have arith- 
metical questions to solve, or long columns of figures to add up. In- 
deed, mental labor of all descriptions is not only difficult, but is irk- 
some in the extreme. 

Before long the evidences of intellectual derangement become more 
evident. The ideas are confused and without logical arrangement ; 
the memory begins to fail, especially in regard to recent occurrences ; 
aud there seems to be a special proclivity to forget words, and to sub- 
stitute others having a similar sound when pronounced, or appearance 
when written. The names of persons and places are particularly diffi- 
cult to recollect. The judgment is weak and vacillating ; the most 
strongly expressed determination is changed apparently without rea- 
son, and again there may be an impossibility of arriving at a decision 
in cases where ordinarily but little reflection would be necessary. Any 
effort toward continuous or severe thought increases the difficulties of 
the mind, and augments the pain or uneasiness which generally exists 
in the head. Illusions, hallucinations, or delusions may be present, 
but are not usually fixed ; and the patient will often laugh at the 
absurd images he has seen, or ideas he has entertained, not five min- 
utes before. Persons thus affected will frequently reason clearly in 
regard to apparitions or voices, of the unreality of which they are fully 
sensible. 

1 For a more complete account of wakefulness in all its relations, see the author's 
treatise on " Sleep and its Derangements." J. B. Lippincott & Co., Philadelphia, 1870. 



34 DISEASES OF THE BRAIN. 

A condition very often present is a morbid apprehension of im- 
pending evil, for which there is no assignable cause, and the nature of 
which the patient can rarely define. He is sure something will happen 
to him, but what, he does not know ; or, if he does designate the form 
of trouble to ensue, he changes from one kind to another without any 
more reason than he had for the erroneous idea in the first place. 
Again, he is afraid that he may do some injurious act either against 
himself or others, and is hence fearful cf being left alone. One patient 
was afraid to cross the ferry from Brooklyn lest he might be tempted 
to throw himself off the boat ; another kept away from railway tracks, 
fearing that he might be led by the sight of a passing train to put 
himself in the way of the engine ; another begged his wife to lock up 
his razors ; and another would not take a warm bath, under the appre- 
hension that he might neglect to turn off the hot water in time. It 
would be easy to enumerate very many more like instances. They 
remind us of " morbid impulse," but the subjects, unlike those of this 
last-named condition, never yield to the excitation. In fact, it is 
not an impulse, but the fear of an impulse, by which they are influ- 
enced. 

The emotioned system participates in the general mental disturbance, 
and indeed is often the part of the mind most prominently deranged. 
The passions are easily roused into activity by slight exciting causes ; 
trifling circumstances produce great annoyance, and the little every- 
day troubles of life appear of vast importance. The disposition accord- 
ingly becomes suspicious, peevish, and fretful. Persons thus affected 
are very far, ordinarily, from being pleasant companions. Many of them 
avoid social intercourse, and shut themselves up in their rooms to brood 
over their real and imaginary disorders. Others, again, plunge into 
dissipation and excesses of every kind, in the vain expectation of being 
able by such means to overcome the disease ; and again others strive, 
by a constant change of one physician for another, or the substitution 
of one quack medicine for another equally quackish, to get relief from 
their mental and physical distress. In some, there are very few de- 
cided symptoms present, except the inability to sleep, and the inca- 
pability of concentrating the mind upon an object of study or labor, 
without inducing pain or discomfort of some kind in the head. 

In all, however, there is the same mental introspection. Every 
symptom is exaggerated ; and, if one with which the patient has suf- 
fered should happen to be absent, he is dissatisfied till it makes its 
appearance again, or till he has, by concentration of his mind on the 
subject, brought it back, and with it an aggravation of all the other 
phenomena. "Doctor," said a gentleman to me a few days since, "I 
am afraid I am getting worse, for last night I slept several hours, and, 
if stupor should set in, I suppose it would be bad." Another, who 
had for several months suffered from an almost perpetual pain in the 



CEREBRAL CONGESTION. 35 

head, was quite sure sensibility was being destroyed when he found 
himself a whole day without it. 

This fixing of the attention upon the body is of course apt to de- 
velop symptoms which would otherwise, doubtless, never make their 
appearance ; and scarcely a day passes that instances in point do not 
come under my observation. The experiments of Mr. Braid in this 
direction are very instructive, and will bear quotation in the present 
connection. He requested four gentlemen, whose ages varied from 
forty to fifty-six years, and who were in good health, to lay their 
hands, palms upward, on a table, and to look at them fixedly for a 
few minutes. They were not to speak, but were, as far as possible, to 
concentrate the attention on the upturned palms, and to await the 
result. In about five minutes one of these gentlemen, a member of 
the Royal Academy, said that he felt a sensation of great cold in the 
hand ; another, an author of distinction, said that at first he thought 
nothing was going to happen, but at last he felt a darting, pricking 
sensation, as if electric sparks were being drawn from the hand ; the 
third, late mayor of a large city, reported that he felt a very uncom- 
fortable sensation of heat come over the hand ; and the fourth, secre- 
tary to an important association, had become rigidly cataleptic, the 
arm being firmly fixed on the table. 1 

Speaking of this subject, Sir Henry Holland 2 says : 

" One limb, for instance, or even a single finger, or a portion of the 
sentient surface of the body, may be taken for observation, and the 
results tested and checked by means wholly independent of the subject 
of experiment, a point often very important to the truth of the result. 

"We have here, as in other parts of the inquiry, to look to the 
respective cases of attention directed by express volition, or suggested 
by some outward cause acting on the mind. In the former and more 
simple case, if a limb be taken for experiment, a peculiar sense of 
weight with a vibratory tingling, or sensations approaching to cramp, 
are produced by the consciousness concentrated upon it. It is difficult 
to describe by words feelings of this nature, evanescent or changing 
at each moment, and different doubtless in different persons ; but 
probably the closest resemblance is to those produced in ordinary cases 
by muscular fatigue or stagnant circulation through the limb. There 
is reason, indeed, to suppose that the muscular structure is actually 
affected in these cases, and frequently even by particular conditions of 
movement, though not volitional in kind." 

Medical men are said, and doubtless with truth — as many cases will 
occur to the mind of the professional reader — to be particularly liable 

1 For many illustrations of the power of the attention over the body, the reader is 
referred to the author's " Spiritualism, and Allied Causes and Conditions of Nervous D& 
rangement." New York : 1 876. 

2 "Chapters on Mental Physiology," p. 24. London: 1852. 



36 DISEASES OF THE BRAIN. 

to be affected with the diseases to which they have given special atten- 
tion ; and every winter, during my course of lectures on the nervous 
system, I am consulted by medical students, who imagine themselves 
to be the subjects of the diseases I have brought to their notice ; and 
in some cases with reason. Under another division of the subject, I 
shall have occasion to return to this matter for further consideration. 

It follows from what has been said, that, if well persons are liable 
to contract diseases through mental concentration, the subjects of 
cerebral hyperemia must be peculiarly prone to the extension of their 
morbid symptoms through a like influence, and in fact this is exactly 
what occurs. A slight accidental sensation in some part of the body 
engages the attention, and becomes a fixture in the clinical history of 
the patient. Neuralgic pains, numbness, spasm, and even paralysis, 
may be thus induced, to say nothing of functional disturbances of the 
several organs. 

Under this latter head there is none more frequently met with than 
what, for a want of a better name, may be called false impotence. To 
the production of this condition, the erroneous ideas which prevail re- 
lative to spermatorrhoea, and the fears excited by the advertisements 
and books of unprincipled quacks, largely contribute. Indeed, it is 
rarely the case that a male patient affected with cerebral hyperemia 
does not at some time or other of its course imagine that he is impo- 
tent, and the only grounds he has for this notion are the facts that he 
has an occasional nocturnal emission, or the exudation of a little ure- 
thral mucus under the influence of sexual excitement. Still the fact is 
not to be overlooked that the predominance of this idea is extremely 
prejudicial to the patient's well-being, and it is therefore important 
that the physician should, by obtaining his confidence and enlightening 
his ignorance, dispel the delusion at the earliest possible moment. 

In addition, there are certain physical symptoms of disordered cere- 
bral action which by their prominence force themselves into notice. 
Thus there are pain, heat, a feeling of fullness or of distention in the 
head, the sensation as if a tight hand encircled it, % or the impression of 
a dragging or clawing character at the vertex. Vertigo is, however, 
the most prominent of all this category of phenomena in the majority 
of cases, and may be so severe as to prevent the patient moving about. 
In one case recently under my charge, the subject, a gentleman of 
about forty years of age, was often seized with intense vertigo while 
walking in the street, and was obliged at such times to seize hold of a 
lamp-post, or, if this was not within reach, to sit down on the nearest 
door-step, or even the curbstone, till the violence of the attack had in 
a measure abated. 

Again, the least movement of the body, the slightest attempt at 
mental exertion, or the most trifling emotional disturbance, is sufficient 
to excite it. At times it is clearly aggravated by indiscretions in diet 



CEREBRAL CONGESTION. 37 

or the ingestion of even a small quantity of any stimulating liquor, and 
at others is present during the whole period of being awake. There 
are two kinds of this vertigo. In one the patient seems to be in mo- 
tion ; in the other the objects about him appear to be tumbling topsy- 
turvy around him. In the latter the ground in front appears to rise 
up to meet him, and hence he walks as if ascending a hill. In some 
cases the two conditions coexist or may alternate. Probably no symp- 
tom is more distressing than this. It almost invariably excites more 
fear of serious consequences than in reality should attend it, and it 
prevents the patient taking that bodily exercise so conducive to his 
restoration to health. In some cases, however, it is entirely absent, 
though such are, I think, rarely met with, and, no matter how intense 
it may be, is scarcely ever accompanied by nausea. 

In other cases headache constitutes the chief physical feature of 
the disease, and even when not predominant is a more or less constant 
attendant on the morbid condition, It may be very severe, unfitting 
the sufferer for the slightest mental or physical exertion, or may con- 
sist of a dull, aching pain, very wearing, but yet bearable. It is ag- 
gravated by any effort to use the mind or body, and especially by any 
cause — such as a dependent position of the head, the use of stimulat- 
ing ingesta, a constriction about the abdomen, chest, or neck — likely 
to increase the amount of the intra-cranial blood. 

In some cases there is no actual pain, except as the immediate con- 
sequence of some one or other of the existing causes mentioned ; but 
the patient is always conscious of an uncomfortable sensation in the 
head, which, if not a pain, is capable of being readily converted into 
one. This is, as I have said, sometimes a mere feeling of fullness or 
tightness, or as if the brain — so a patient described it — were "being 
gathered together into a heap," or, as another said, were "being 
scratched with a claw." Again, there is the impression that the head 
is exactly balanced on a very sharp point, and that some effort is 
required to keep it from falling off. 

Usually the painful sensations in the head disappear toward night, 
or on the attempt to sleep, but resume their violence as soon as the 
patient awakes in the morning. 

The special senses could scarcely be expected to escape giving 
evidences of derangement, and hence among the chief manifestations 
of the intra-cranial disorder are those connected with the perceptive 
organs. 

Thus there are noises in the ears, such as roaring, rumbling, or sing- 
ing, and occasionally loud reports, such as might be produced by the 
discharge of fire-arms. A gentleman, recently under my care for the 
affection in question, informed me that when he first experienced the 
sensation mentioned he was sitting in his library, quietly reading, 
when he suddenly heard a report as if a pistol had been shot off within 



38 DISEASES OF THE BRAIN. 

a foot of his head. He jumped to his feet, expecting to see an assail- 
ant behind him, but, to his surprise, there was no one to be seen, and it 
was very evident that no explosion had taken place. He was greatly 
astonished at this, but attributed the whole matter to an exaggeration, 
excited by his irritable nervous system, of some street noise. He had 
no further experience of the kind till the following morning, when, on 
rising from bed after a wretched night of sleeplessness, he again heard 
the sound, and this time it was as nearly as possible like the noise 
produced by striking two stoutly bound books together close to his 
ears. After this there was scarcely a day that the sound was not 
heard. It was entirely subjective, as persons in close proximity to him 
at the time heard nothing. 

Several such cases have come under my observation. It is not in 
all that the sound appears to be in the ears. In some it has seemed 
to be located in different parts of the head, generally, however, in the 
posterior region. 

In some cases patients have experienced the sensation as if some- 
thing snapped or gave way within the head, and this has, in a few 
rare instances, been attended with the sudden disappearance of some 
of the more striking symptoms. Thus, a young lady, in consequence 
of an intense emotion, was seized with sudden vertigo and pain in the 
head, and fell to the floor unconscious. Recovering her senses in 
a few minutes, she found herself unable to speak a word, though she 
uttered in an excited way inarticulate sounds having no resemblance 
to speech. This condition continued for several hours, when she sud- 
denly felt "something snap" in the head, and she instantly recovered 
the power of talking. The vertigo, pain in the head, and other symp- 
toms, persisted for two or three months afterward. 

In another case the onset of the disease, in a gentleman who had 
for many years overworked his brain, was extremely sudden, and was 
attended with facial paralysis. I treated him for this latter condition 
with electricity, with but little benefit ; but one day he struck his 
head violently against a gas-burner hanging over his desk, and shortly 
afterward felt something give way within his head with a sharp, snap- 
ping sound, and the paralysis instantly disappeared, after having lasted 
some five or six days. 

Such cases are, in the present state of our knowledge, inexplicable. 

The ear becomes hypersesthetic, and loud noises are therefore dis- 
agreeable. At times the sense of hearing is morbidly acute, while at 
others it is markedly impaired. Sounds are misinterpreted with some 
persons, and illusions result. This is especially the case at night, when 
the patient is lying awake, the mind stretched to its utmost tension. 
A gentleman informed me that a circumstance with which most per- 
sons are familiar — the conversion of the sound of the ticking of a clock 
into some phrase or other — was to him a matter of agonizing weari- 



CEREBRAL CONGESTION. 39 

ness. Night after night as he lay in bed, the ticking of a large clock 
in the hall seemed to be the constant repetition of the word " fare- 
well." Not wishing to reveal the matter to others, he endured for 
many nights the consequent suffering, till finally he made an excuse for 
leaving the city. But still the wheels of the railway cars seemed to be 
uttering the word " farewell," and it was only after a fatiguing journey 
to Baltimore and repose in a quiet room that he escaped the infliction. 

In addition to illusions, hallucinations of hearing are not uncom- 
mon, and are usually in the form of whispered words, which the 
patient hears with as much vividness as though they were real utter- 
ances. Like the misinterpretations of real sensorial impressions, these 
are usually experienced at night, and may be excited by any circum- 
stance, mental or physical, which tends to increase the amount of blood 
circulating in the intra -cranial vessels. Thus, a powerful emotion, an 
unusually severe mental task, a strong muscular effort, or a dependent 
position of the head, may induce them. In one case, that of a gentle- 
man of rather obese development, a whisper of some kind or other 
was always heard when he stooped to button his gaiter-boots. In 
another, straining in the water-closet frequently caused a like symp- 
tom. In one very interesting instance the sounds were like those of 
musical instruments, and were arranged into familiar tunes, to the no 
small satisfaction of the subject ; and in another they assumed the 
similitude of the bark of a dog. Occasionally they are in the form 
of commands to perpetrate some act of violence, such as suicide. A 
patient, who came from Brooklyn to consult me, heard a voice whis- 
pering in his ear, and ordering him to throw himself into the river. 
" What is the use of your going to see a physician ? " it said. " The 
best thing you can do is to kill yourself. You are of no service to 
yourself or any one else. Jump overboard and end the matter at 
once." Though these hallucinations never imposed upon the reason 
of the patient, they were nevertheless sufficiently distressing, giving 
rise, as they did, to the fear that he might, some day or other, be in- 
fluenced by them to commit an act which he abhorred. 

The aural speculum is almost, if not quite, as valuable as the oph- 
thalmoscope in affording important information relative to the affec- 
tion under notice ; and I have been in the habit for the last five years 
of employing it in every case presenting the more obvious features of 
the disease. I do not mean to be understood as intimating that posi- 
tively affirmative results are to be obtained in all instances, but neither 
are they of any other single symptom. That the tympanum does 
afford an indication of the state of the intra-cranial circulation is 
sufficiently evident, from a consideration of the experiments performed 
by my friend Prof. Roosa and myself l relative to the influence of the 

1 " The Influence of the Disulphate of Quinine over the Intra-Cranial Circulation." 
Psychological and Medico-Legal Journal, October, 1874, p. 230. 



40 DISEASES OF THE BRAIN. 

sulphate of quinine, the results of which have been amply confirmed 
by the subsequent investigations of Prof. Roosa, as well as by those 
of other observers. 

In the cerebral disorder under notice, evident congestion will almost 
always be observed of the vessels over the handle of the malleus, and 
the tympanum will be seen to be of a light pinkish color. In some 
cases we are prevented making the usual examination owing to the 
accumulation of cerumen. This must be removed by forceps or by 
washing, and the inspection deferred till next day. 

I may add that physicians, wishing to observe the connection be- 
tween cerebral hyperemia and tympanic congestion, have a ready 
method of satisfying themselves on this point by examining the tym- 
panum before and after the subject has inhaled a few drops of the 
nitrite of amyl. This was first done, so far as I am aware, by Mr. 
Galton, 1 and detailed in his paper entitled " Notes on the Condition 
of the Tympanic Membrane in the Insane." 

The faculty of vision is almost invariably more or less disturbed. 
Sometimes there are bright flashes of light, from over-excitation of the 
retina, and these, like the other symptoms, are rendered more intense 
upon mental or physical exertion. At other times dark spots — muscce 
volitantes — render the vision indistinct ; and again there is the appear- 
ance of an undulatory vapor, such as is seen around a hot stove, or on 
a plain heated by the sun. The conjunctivae are suffused ; the pupils 
contracted. There is intolerance of light, and motion of the eye- 
balls is painful, and the ophthalmic symptoms are aggravated by the 
effort to use the eyes. The ocular muscles easily become fatigued, 
and hence pain is excited by any attempt to read or to adjust the 
visual foci for near objects. 

Ophthalmoscopic examination shows the arteries of the retina to be 
increased in size and tortuosity, and vessels which in health are not visi- 
ble are now clearly perceived. The optic disk is often more or less 
congested, exhibiting the appearance to which Allbutt has applied the 
name "Congestion Papilla," but which is perhaps more generally 
known as "choked disk." The tint of the choroid is deeper than it is 
when in a normal condition. 

The effect of cerebral congestion in giving rise to visual hallucina- 
tions has long been known, though it often happens that in practice 
the value of the fact as an indication of the state of the intra-cranial cir- 
culation is in a great measure disregarded. In another work 2 I have 
considered the subject of hallucinations of sight at some length, and, as 
showing the influence of undoubted cerebral congestion in producing 
them, I quote the following case w T hich occurred in my own experience : 

1 "West Riding Lunatic Asylum Medical Reports," vol. iii., 18Y3, p. 258. 

2 " Spiritualism and Allied Causes and Conditions of Nervous Derangement." New 
York, 1876, p. 8. 



CEREBRAL CONGESTION. 41 

"A gentleman under the professional charge of the writer can 
always cause the appearance of images by tying a handkerchief moder- 
ately tight around his neck, and there is one form which is always 
the first to come and the last to disappear. It consists of a male figure 
clothed in the costume worn in England three hundred years ago, and 
bearing a striking resemblance to the portraits of Sir Walter Raleigh. 
This figure not only imposes on the sight, but also on the hearing ; for 
questions put to it are answered promptly." 

" A similar instance is related in ' Nicholson's Journal.' 1 i I know a 
gentleman,' he states, 'in the vigor of life, who, in my opinion, is not 
exceeded by any one in acquired knowledge and originality of deep 
research, and who for nine months in succession was always visited 
by a figure of the same man, threatening to destroy him, at the time 
of his going to rest. It appeared upon his lying down, and instantly 
disappeared when he resumed the erect position.' " 

A case somewhat like the first of the two foregoing is referred to 
by De Boismont, 2 in which an individual was able to obtain hallucina- 
tions of sight by inclining his head a little forward. By this move- 
ment, the return of blood from the interior of the cranium was pre- 
vented, and hence a state of repletion favorable to the production of 
hallucinations was induced. 

Now, in the state of cerebral hyperemia which results from exces- 
sive brain-work or intense emotional disturbance, a condition exists 
not essentially different from that present in the case referred to, ex- 
cept in the circumstance that the excess of blood is mainly arterial, 
instead of venous, and that hence the congestion is more active than 
passive. But it must be borne in mind that it requires a very great 
degree of hyperemia to cause the production of visual hallucinations, 
and therefore that we are not to expect them to occur in all patients 
who are its subjects. So far as my own experience extends, only about 
one in five exhibits the symptom with any degree of distinctness. 

Double vision is occasionally a phenomenon of the disease in ques- 
tion, though it is generally transient, and, as Krishaber remarks, ordi- 
narily only manifested in regard to bright objects. 

This author also speaks of a peculiarity of sight which has not 
come under my notice. " A patient," he says, " looks at himself in a 
glass with astonishment, as if he had forgotten his appearance. An- 
other is horrified at his image, which represents a being altogether of 
different traits from those which he conceived himself to possess. But 
he is not alarmed, for he knows that it is only his perception which is 
changed. This aberration exists not only as regards his own person, 
but other objects as well. The patient finds men and things changed ; 



1 Vol. vi., p. 166. 

2 " History of Dreams, Visions, Apparitions, etc." American edition. Philadelphiaj 



1835. 



42 DISEASES OF THE BRAIN. 

he is astonished, always astonished, and it seems to him that he is a 
being transported to another planet." ' 

The sense of smell is very often lost, perverted, or intensely exalted. 
Perhaps the second named of these changes is the one most frequently 
met with. I have a patient now under my care, a gentleman, who 
from over-mental work is suffering from cerebral hyperemia, and who 
constantly, while awake, smells the odor of illuminating gas. So strong 
is this, that he is at times unable to resist the impression that gas is 
escaping somewhere, and he goes from burner to burner of his resi- 
dence and office seeking for the imaginary leak. Another is constantly 
sensible of the smell of turpentine or new paint, and another has the 
odor of mint constantly present in his nostrils. 

The taste is also occasionally affected in like manner, usually, so 
far as my experience goes, in the way of perversion. " Things don't 
taste as they used to," is a common complaint, and the saliva and buc- 
cal mucus often give the gustatory impression of other substances. It 
is not at all unlikely, however, that " the bad taste in the mouth," so 
often mentioned by patients, is due to a real change in the properties 
of the saliva or mucus. I have observed several cases in which any 
mental or emotional strain was sufficient to cause a bitter or other un- 
pleasant taste in the mouth, and the same phenomenon is quite common 
as a consequence of gastric disturbance. Krishaber cites two cases in 
which both smell and taste were entirely abolished. 

Sensation and the power of motion are usually affected, and general- 
ly, though not always, on one side of the body only. Thus, the arm or 
the leg feels heavy, and a feeling as of ants crawling over it, pins and 
needles sticking in it, or as if the limb were " asleep," is experienced. 
Sometimes these sensations are confined to the face, the muscles of 
which feel drawn or tight, and the skin of which has the various indica- 
tions of anaesthesia mentioned. Most frequently, however, they are, I 
think, experienced on the scalp, giving rise to the several sensations 
already mentioned. 

Again, there is an exaltation of the sensibility of the skin and of 
the sensory nerves generally, and thus neuralgic pains are felt in vari- 
ous parts of the body ; or the cutaneous surface is extremely sensitive 
to the impression made upon it, whether of heat, cold, or slight pres- 
sure. 

Slight convulsive actions or twitchings of individual muscles or 
groups of muscles are generally present. Sometimes a few fibers 
only are affected. The face, and especially the eye-lids and angles of 
the mouth, is particularly liable to be thus involved. The muscular 
strength is usually weakened. The patient tires after slight physical 
exertion, and occasionally certain muscles, such as the deltoid and 
tibialis anticus, become distinctly paretic, so that there is an impair- 

1 Op. tit., p. 168. 



CEREBRAL CONGESTION. 43 

ment of the ability to raise the arm from the side or to elevate the 
foot sufficiently high in walking to clear ordinary inequalities in the 
pavement. The dynamometer shows the grasp of the hand of one or 
other side, or of both, to be weakened, and the line made by the dy- 
namograph is zigzag or uniformly depressed. 

The appetite is capricious, and the stomach acts imperfectly and 
sluggishly. The gastric juice is not secreted in sufficient quantity for 
the purposes of digestion, and, the peristaltic action of the stomach 
being weakened, the food remains within it a long time undigested 
and undergoing fermentation. Regurgitations, both of the solid con- 
tents and of gases, are common, and the patient tastes his meals sev- 
eral hours after they have been swallowed. Gases accumulate in the 
stomach, and give rise to the sense of fullness experienced even after a 
very slight repast has been taken. Such symptoms are usually classed 
under the name of "nervous dyspepsia," a not improper designation, 
if it does not lead us into the error of regarding them as of primary 
importance, instead of considering them, as they are, merely consequent 
on the head trouble. 

The bowels are ordinarily costive, though at times this condition 
alternates with diarrhoea. 

The urine is in some patients scanty and high-colored, in others it 
is profuse and almost as pale as water. Oxalate of lime is often pres- 
ent, and an excess of phosphates an invariable condition, so far as 
my experience extends. I have already spoken of this circumstance. 
Whether or not the phosphates in the urine are to be regarded as the 
ashes of the nervous system, and hence a measure of the amount of 
nerve tissue decomposed, there is no doubt that they are inordinately 
increased after intense mental or emotional strain. 

I have spoken of the heat of the head of which the patient gener- 
ally complains. That there is a real increase of temperature can often 
be perceived by the hand or by the use of an ordinary thermometer. 
But in some cases the actual rise of temperature is so slight, notwith- 
standing the feeling of heat which the patient experiences, that we can- 
not detect it by either of these means. In such cases resort should be 
had to the thermo-electric differential calorimeter of Lombard, by 
which very minute changes of temperature can be detected, and the 
part of the brain in which the temperature is highest be readily ascer- 
tained. The experiments of Lombard, performed several years ago, 
show very beautifully the influence of cerebral action in augmenting 
the external heat of the head, and it may be remembered that, over 
two years ago, I detailed to the Neurological Society the results of 
some experiments of my own in the same direction. For several years 
past I have never examined a patient presenting the more obvious 
features of cerebral hyperemia without carefully determining the sur- 
face temperature of various parts of the scalp. At times and in some 



44 DISEASES OF THE BRAIN. 

regions the elevation reaches two degrees of centigrade above the 
normal standard. 1 

But one of the chief categories of symptoms remains to be consid- 
ered — chief, at least, so far as the more obvious appearances go, though, 
like the other visceral derangements, I must regard these as being due 
to the brain disorder — and that is the group of phenomena connected 
with the heart. To Krishaber, in the work already cited, belongs the 
credit of being the first to call attention to this remarkable series, for 
in the publication of my own, to which I have referred, it was in a great 
measure overlooked. As Krishaber remarks, the troubles of the circu- 
lation consist especially in an irritability of the vascular system, so that 
the least movement, such as rising erect from the sitting posture, or to 
the sitting from the recumbent, leads to an acceleration of the pulse 
of from 20 to 30 or even 40 beats a minute. Besides this, there are 
frequent and violent palpitations, either spontaneous, or provoked by 
the most insignificant causes, either mental or physical. 

Emotional excitement is, however, the most prolific cause of cardiac 
disturbance in patients affected with cerebral hyperemia, and at times 
leads to serious results. The pulsations of the heart may be so irregu- 
lar and the action of the organ so strong as to induce grave inter- 
ference with the respiratory apparatus. Upon one occasion a lady, 
while in my consulting-room, was seized with a paroxysm of the kind 
in question, of so severe a character that for a moment or two I thought 
she was about to die. For several months she had been wakeful, had 
suffered from vertigo and slight pain in the head, and, while relating to 
me her symptoms, a blast near by, where a cellar was being excavated, 
exploded, and produced so violent and sudden a shock as to bring on 
the excessive cardiac action mentioned. The heart throbbed with so 
great a degree of violence that its pulsations could be readily seen 
through her dress and heard at the distance of two or three feet ; her 
face and neck became livid, and, gasping for breath, she fell to the floor 
insensible. In a very short time, however, the inordinate movements 
ceased, and she recovered consciousness. 

Physical examination of the heart fails in these cases to reveal 
the existence of any organic lesion. 

In the intervals between the paroxysms of inordinate cardiac ac- 

1 Since the above was written I have become acquainted with some recent experiments 
of Prof. Broca, of Paris, in the same direction. As he does not refer to either Lom- 
bard's or my own experiments, though the former (" Experiments on the Relation of Heat 
to Mental Work") were published in the New York Medical Journal, January, 1867, p. 
198, and a synopsis of my own in the Journal of Nervous and Mental Disease, January, 
1876, I presume he is unacquainted with cither. Prof. Broca ascertained by means of 
thermometers, applied to different parts of the scalp, that the external temperature was 
affected by different internal morbid and physiological conditions, and hence confirmed 
the previous observations of Lombard and myself. His experiments would have yielded 
much more delicate and accurate results if he had employed Lombard's instrument. 



CEREBRAL CONGESTION. 45 

tion, the pulse is small, often slow, soft, compressible, but by no 
means regular, either in force or frequency. Intermissions of the 
beats are a common phenomenon, and give rise to anxiety and morbid 
apprehensions in the patient. 

Krishaber states that at the very beginning of the disorder there 
is sometimes present a series of phenomena simulating fever, such 
as a chill, followed by a distinct period of febrile excitement. Dur- 
ing this last stage the temperature of the body is elevated almost 
half a degree centigrade, or nearly a whole degree of our scale, and 
may even be double this. This accession may be repeated with some 
degree of periodicity, but it soon ceases, and does not reappear after 
the full development of the disease. 

I have observed this condition in about one third of the cases 
that have come under my observation, though usually close question- 
ing is necessary to elucidate the fact of its existence, so little im- 
pression does it make upon the mind of the patient. Sometimes, 
however, the paroxysms are of such severity as to excite the belief 
that they are of malarious origin, and, being treated with quinine, 
they and the other symptoms attendant on the disease are greatly 
aggravated. 

During the most intense period of the disease there are occasion- 
ally paroxysms characterized by entire inability to move a muscle of 
the body, the consciousness, respiration, and circulation not being ma- 
terially disturbed. I have never had a case which exhibited these 
symptoms, though Krishaber appears to regard them as not uncommon. 
On the other hand, syncope with complete loss of consciousness, which 
he speaks of as rare, is, according to my experience, by no means 
uncommon. With both of these conditions, there is an almost con- 
tinuous precordial pain, sometimes severe enough to excite the idea 
of the existence of angina pectoris, and causing the gravest appre- 
hensions on the part of the patient and his friends. 

That one of the primary effects of intellectual exertion or emo- 
tional disturbance is an increase in the amount of blood circulating 
through the brain, does not admit of a doubt, except from those who, 
still refusing to learn, contend that the cerebral circulation is not sub- 
ject to variation under any circumstances. Experimental physiology 
has,- however, determined this point so positively in the affirmative 
that it is scarcely necessary to adduce the evidence in its support. It 
will be sufficient to recall the numerous facts observed by others and 
myself with reference to the immediate cause of sleep, by which it is 
shown that during the condition of wakefulness the quantity of blood 
in the brain is much greater than it is during sleep, the first being a 
state of intellectual activity, the latter one of almost complete cere- 
bral rest. 

Excessive mental exercise inordinately augments the activity of 



46 DISEASES OF THE BRAIN. 

the cerebral circulation. The blood-vessels become over-distended, 
and, if the brain be kept long in a condition of extraordinary action, 
they may be rendered incapable of returning spontaneously to their 
normal dimensions. Like a bladder filled to repletion with urine, 
they become in a manner paralyzed and unable to contract upon their 
contents. They lose, to a certain extent, their elasticity, and, like the 
India-rubber band kept too long around a large bundle of papers, they 
do not regain their natural size even when the distention is removed. 
A state of cerebral hyperemia is thus induced, which gives rise to a 
set of perfectly characteristic symptoms, and which is fraught with 
peril to those in whom it occurs. 

In a monograph published some seven years ago, Dr. M. Krishaber l 
described a disorder of the brain and heart which is probably identi- 
cal with the one under consideration, and to which, under the name 
of cerebral hyperemia, or the prodromatic stage of cerebral hypere- 
mia, I called attention in the first edition of my "Treatise on Diseases 
of the Nervous System," published in 1871. Krishaber's studies have 
very considerably advanced our knowledge of the subject, and, as my 
own more recent investigations and enlarged experience have tended 
still further to the elucidation of a very interesting and important 
condition of the nervous system, I have thought it would not be out 
of place to bring some of the more notable results of our labors to the 
notice of the Neurological Society. It may be as well, however, to 
state here, at the outset, that I differ with Krishaber entirely relative 
to the pathology of the disorder we have both described, and that I 
am of the opinion that the cardiac symptoms upon which he lays 
great stress are really of quite secondary importance. In other re- 
spects there is no essential point of difference between us in the repre- 
sentations of an affection studied independently of each other, and 
from altogether different standpoints. 

The disease is sometimes developed with great suddenness, but 
ordinarily it advances little by little to completeness. When the 
former is the case, the patient experiences, under the influence of 
great mental excitement, pain in the head, vertigo, an inability to 
speak, or, at least, imperfection of articulation. There' are noises in 
the ears, flashes of light before the eyes, and occasionally for a short 
time double vision. The heart beats with increased force and rapid- 
ity, and is more or less irregular in its action ; the face is flushed, and 
a feeling of suffocation is experienced. If he attempts to walk, his 
gait is uncertain or staggering, not only in consequence of the vertigo 
present, but from actual loss of power in the limbs. Numbness is 
commonly felt in some part of the body, and clonic spasms of the 
muscles, notably of those of the face, are generally present. 

With all these physical symptoms, there are others indicating men- 
1 "De la nevropathie eerebro-cardiaque." Paris, 1873. 



CEREBRAL CONGESTION. 47 

tal disturbance. Chief among these are hallucinations, or illusions of 
the senses, particularly of sight and hearing. Insomnia is an almost 
invariable attendant, and what little sleep the patient obtains is inter- 
rupted by unpleasant or even frightful dreams. Gradually the disor- 
der becomes established, and then other functions, especially those 
connected with digestion, are deranged. From the first the urine is 
loaded with urates and phosphates. 

As instances of the suddenness with which the disease may make 
its onset, I cite the following cases from my note-book : 

F. H., a gentleman engaged in a manufacturing business which re- 
quired all his attention to make it profitable, was informed one morn- 
ing by his superintendent that a large lot of material had been spoiled. 
He at once experienced an intense sensation of vertigo, a sharp pain in 
the head, palpitation of the heart, and would have fallen, had he not 
been supported by the bystanders. There were also a roaring sound 
in the ears and flashes of light before the eyes. On attempting to 
stand, the vertigo and palpitations were increased. There was at no 
time loss of consciousness, though the ideas were confused and the 
speech thick. In the course of a few hours the severity of these 
symptoms diminished, but that night he was unable to sleep, and in 
the morning the morbid phenomena reappeared, though with dimin- 
ished violence. For several months afterward he was troubled with 
wakefulness, a sense of fullness and tightness in the head, occasional 
weakness of the limbs, slight numbness, and a total inability to exert 
his mind in his business affairs without an increase in all the symp- 
toms. Under appropriate treatment he entirely recovered. 

S. L., a book-keeper, after a day of unusually arduous work, left 
his place of business to go home. He had hardly taken half a dozen 
steps when he was seized with vertigo, and fell unconscious on the side- 
walk. He almost immediately regained his senses, but, on trying to 
stand, found that he was paralyzed in both legs, and that the least 
motion of the body brought on a return of the vertigo, which was now 
attended with pain in the head, mostly in the frontal region, noises 
in the ears and indistinctness of vision. On attempting to speak, 
his articulation was so imperfect that he could scarcely be understood. 
There was an uneasy feeling at the pit of the stomach, but neither 
nausea nor palpitation of the heart, though the action of this organ 
was irregular. He was taken home in a carriage, and after a sleepless 
night found himself very little better, except in the fact that, though 
his legs were still weak, there was no absolute paralysis. Gradually he 
got somewhat better, though walking always produced vertigo, and 
his gait was similar to that of a partially drunken man, as he found 
it impossible to avoid a zigzag course, or a decided tendency to sidle 
over to the edge of the pavement. Sleep was almost every night im- 
perfect, being disturbed by dreams of difficulties from which he could 



48 DISEASES OF THE BRAIN. 

not extricate himself, such as the house being on fire, and, on his spring- 
ing from bed, discovering his door to be locked on the outside ; falling 
into the water, and being on the point of drowning from inability to 
divest himself of heavy boots, and so on. Mental application was im- 
possible without leading to an aggravation of all his symptoms, and 
the least emotional excitement was sufficient to augment them to a 
high degree. He suffered in this manner for nearly a year, before re- 
lief was obtained, being in that time treated with remedies directed to 
the removal of cerebral anaemia, when, in fact, the intra-cranial condi- 
tion was directly the opposite. 

M. S., a young lady, aged nineteen, and without notable predisposi- 
tion to neurotic disturbances, was deeply chagrined at not being in- 
vited to a ball at which she had confidently anticipated being present. 
While talking the matter over with some friends, she suddenly expe- 
rienced a severe pain in the head, vertigo, noises in the ears, flashes of 
light alternating with darkness, and violent palpitation of the heart. 
At the same time a peculiar thrilling sensation was felt throughout the 
body, especially on the left side. These symptoms continued with 
great intensity all that day, notwithstanding that stimulants and anti- 
spasmodics were administered in large quantities by the physicians 
called to attend her. During the night, every attempt to turn over in 
bed was attended with vertigo and palpitation of the heart. For over 
a year there was very little improvement, and the course of the disease 
was not essentially different from the other cases cited. The most dis- 
tressing symptom in her case was the persistence of the insomnia, it 
rarely happening that she obtained over an hour or two of unrefresh- 
ing slumber. When she came under my care, some thirteen months 
after the inception of the disease, I found that the affection, though 
mitigated in the violence of the attendant phenomena, was still suffi- 
ciently distressing to impair her capacity for enjoyment and her useful- 
ness to others. Recognizing the existence of congestion of the brain 
rather than anaemia, for which she had uniformly been treated, I acted 
accordingly, and had the satisfaction of seeing her gradually improve, 
till, at the end of less than six weeks, she was as well as she ever had 
been in her life. 

These cases are cited, not as exhibiting perfect representations of 
cerebral hyperemia, but merely for the purpose of illustrating the 
suddenness with which the condition may be induced. They are se- 
lected at random from many others occurring in my hospital and pri- 
vate practice, and detailed in my note-book. 

Eventually, no matter how brusque may be the development of the 
symptoms, the course of the disease is not materially different from 
that of the more gradually established form next to be described. In- 
deed, there are no differences except as regards the order of sequence 
in which the symptoms ensue and in the fact that, in the present form, 



CEREBRAL CONGESTION. 49 

there is, in the beginning, a greater degree of intensity in the abnormal 
manifestations. 

In the majority of cases, therefore, the affection is evolved more 
slowly, and the order of appearances of the phenomena somewhat dif- 
ferent. 

The foregoing constitute the ordinary assemblage of symptoms 
which are first met lvith in congestion of the brain. Some of them 
may be absent, others so slightly manifested as to escape ordinary ob- 
servation, and others, again, so strongly exhibited as to excite the grave 
apprehensions of the patient and his friends, and to require him to keep 
his bed. Generally, however, they are not so severe as to prevent him 
attending in a measure to his ordinary avocations, and they may alto- 
gether disappear, either spontaneously or in consequence of appropriate 
medical treatment. 

A spontaneous cure is, however, rare, and, without proper manage- 
ment on the part of the patient or his medical attendant, the symptoms 
pass, sooner or later, into one of the fully developed forms mentioned. 
Thus, of the cases that have been under my observation, the disease 
was arrested at the first stage in about ninety-five per cent, by appro- 
priate treatment, while there was not a single instance of spontaneous 
cure. 

The fact that abscesses of the liver may be associated with cere- 
bral hyperemia, probably as a direct result, was pointed out by me " a 
short time since, and several cases detailed in which aspiration had led 
to the evacuation of pus from the liver. Since the publication of the 
original paper on the subject, other similar cases have come under my 
notice, and like ones have been reported by other observers. 3 It is 
probable, however, that other brain lesions — as is well known of blows 
upon the head — are capable of inducing the condition in question. 
The subject will be more appropriately considered in detail in my 
forthcoming work on mental disorders. 

Second Stage, a. The Apoplectic Form. — Occasionally this va- 
riety of cerebral congestion is initial, but ordinarily it is preceded by 
the group of symptoms just detailed. In either event the onset is gen- 
erally sudden. The patient is perhaps walking in the street, when he 
staggers, loses consciousness, and falls. The loss of intelligence and 
sensibility is, however, rarely complete, and may last but a few minutes 
or even seconds, though sometimes continuing for several hours. 

Paralysis, to a greater or less extent, is always present for a time. 

1 " On Obscure Abscesses of the Liver : their Association with Hypochondria and 
their Treatment." St. Louis Clinical Record, June, 1878. 

2 " The Diagnosis of Abscess of the Liver by Symptoms of Cerebral Hyperemia," etc. 
By J. Marion Sims, M. D. Virginia Medical Monthly, January, 1880. 

"Hyperemia of the Brain associated with Hepatic Abscess," by W. H. De Witt, M. D- 
Medical Gazette, April 3, 1880. 
5 



50 DISEASES OF THE BRAIN. 

One limb only may be affected, or those of one side, or all four mem- 
bers. It is never complete, the patient being able to perform some 
movements, though not to exert his full strength. The face is rarely 
involved, and the patient, though answering briefly when addressed in 
a loud voice, speaks indistinctly and with difficulty. The respiration 
is loud, slow, but rarely stertorous, and it is not often that there is 
puffing of the lips and cheeks. The pulse is slow, hard, and full. 
Sometimes the face is flushed, and sometimes it is unusually pale. 
The sphincters generally retain their power. The senses, though 
weakened, are often capable of being exercised by tolerably strong 
excitations. A bright light causes uneasiness and closure of the eye- 
lids. A loud noise is productive of discomfort, and a limb, when 
pinched, is withdrawn. The power of the mind is greatly lessened, 
and some faculties are altogether abolished. Answers, more or less 
direct, are given to simple questions put in a loud tone, but even 
moderate intellectual action seems to be impossible. 

Gradually the attack passes off, leaving the patient in a state of 
mental and physical depression, which may last for several days. The 
paralysis usually disappears, but occasionally it does not, one or more 
limbs or muscles remaining permanently, or for a long time, disabled. 

It sometimes happens, however, that the termination is not so favor- 
able. The vessels may remain congested, serum may be effused, and 
death may result without there being any vascular lesion. Two cases 
have come under my notice, in which death ensued from this cause in 
first attacks.. 

A person who has once had a paroxysm, such as has been described, 
is thereby rendered more liable to subsequent seizures, each one of 
which still further permanently impairs his mental and physical powers. 
In one case, occurring in my practice, there have been eleven attacks 
in five years ; and in another, fourteen in four years. In both of these, 
and in several similar instances I have witnessed, there was paralysis, 
which had become more profound with each accession. It is therefore 
inexact to say, as do some writers, that the paralysis of cerebral con- 
gestion always disappears in a short time. 

The apoplectic form of cerebral congestion is more common than 
any other of the fully developed varieties, about one half of all the 
cases being of this type. 

b. The Paralytic Form. — Like the apoplectic variety, this may be 
unpreceded by the premonitory symptoms constituting the first stage, 
but usually they have been present. The loss of power or of sensibil- 
ity, or of both, may be very circumscribed, limited to a single group 
of muscles in the one case, or a small portion of the cutaneous surface 
in the other, or one entire side, or both sides of the body, may be in- 
volved. It differs from the apoplectic form in no essential respect, 
except that there is no loss of consciousness. Its onset is sudden. 



CEREBRAL CONGESTION. 51 

c. The Convulsive Form. — This, like the variety just described, 
may come on suddenly, or may be preceded by premonitory symptoms. 
The phenomena of the attack do not generally differ from those attend- 
ant on an ordinary epileptic paroxysm, except that there is never an 
aura, and no peculiar cry, such as is so often met with in pure epilepsy. 
There is the same tonic spasm, followed by clonic convulsions, which 
may or may not be confined to one side of the body, and which may or 
may not be followed by temporary or long-continued paralysis. Stupor 
likewise supervenes, but is neither of so long a duration nor so pro- 
found as in true epilepsy. 

In other cases, and especially in infants or young children, there is 
no loss of consciousness. The pain in the head is intense, the pupils 
are contracted and insensible to light ; there are vomiting and accelera- 
tion of the pulse. The convulsive movements, which may be either 
tonic or clonic, or both alternately, are either quite general or confined 
to a single limb or even a group of muscles. 

This form of cerebral congestion is never developed during sleep, 
for then the brain contains less blood than when the individual is awake. 
It may occur during stupor induced by certain drugs, constriction of 
the neck, or a dependent position of the head ; but stupor is not sleep, 
although the two conditions are frequently confounded. Convulsions 
occurring during ordinary sleep are never the result of congestion. 
This point will be more fully considered under the head of epilepsy. 

After the stupor the patient may feel comparatively well, or there 
may be delirium, continuing for several hours. As in the apoplectic 
form, there may be a succession of attacks, and the mind and physical 
power of the patient are thereby greatly weakened. 

The variety under consideration is, perhaps, more liable to occur in 
individuals past the age of forty, though I have witnessed several cases 
in quite young persons. It is not often met with in old age, and, when 
it is, is generally fatal, probably from secondary lesion. A majority 
of the cases of epileptiform convulsions, occurring for the first time in 
persons over the age of forty, are instances of the convulsive form of 
cerebral congestion. 

d. The Soporific Form. — This form will be more fully described 
under the head of passive cerebral congestion, to which condition it is 
almost entirely restricted. It differs from the apoplectic form in the 
circumstance that the invasion is gradual ; and from this and the para- 
lytic in the fact that there is no paralysis, although the limbs may be 
in a state of general resolution. The chief phenomena are pain in the 
head, dilatation of the pupils, and stupor. 

e. TJie Maniacal Form. — This variety, though not so common as 
either of the others, is 'yet not infrequent. It is characterized by an 
accession of mental derangement not materially different from that in- 
dicative of acute mania. The delirium is of a very active character, the 



52 DISEASES OF THE BRAIN. 

eyes are suffused, the face is red, the head hot, the motility active, and 
the whole manner, character, disposition, and mental processes are 
changed. During the paroxysm, the patient may commit some act of 
violence, and it almost always happens that his combative proclivities 
are aroused. He may likewise attempt to injure himself. 

The attack may come on with great suddenness. In the case of a 
gentleman recently under my charge, it was the result of eating a hearty 
meal in a great hurry at a railway station. A few minutes after his 
return to the train, he was attacked with furious delirium, during which 
he attempted to injure himself and all within his reach. He was seized 
and held, but continued, as far as he was able, to bite, scratch, and 
kick at those who were near him. The paroxysm lasted about two 
hours. He then fell into a heavy stupor, from which he did not arouse 
for two hours longer. For several days his mind was weak, and there 
was numbness in various parts of his body. Gradually, however, he 
regained his former powers, but he suffered from occasional confusion 
of thought and difficulty of speech, with headache and wakefulness, for 
several weeks. 

In another case — that of a boy thirteen years of age — it was charac- 
terized by paroxysms of maniacal excitement, during which the subject 
attempted to bite and otherwise to injure those around him, indulging 
at the same time in the most profane and obscene language. These 
seizures took place about once a week. There was generally a distinct 
recollection of all the events which had happened. In several other 
cases, the seizures were the result of malarial poisoning, and were ex- 
actly periodical in their occurrence. Paralysis, as in the other forms, 
may be one of the phenomena of this variety of cerebral congestion. 
Death may take place during the attack, or from secondary lesions 
afterward. 1 What is called temporary insanity, mania ephemera, or 
impulsive insanity, generally depends upon cerebral congestion. The 
subject, therefore, is of vast importance in its medico-legal relations. 2 

/. The Aphasic Form, — The inception of this type is usually very 
sudden. There may or may not be the accompaniments of pain in the 
head, vertigo, and confusion of mind. The chief symptom is the im- 
pairment or abolition of the faculty of speech, and this may be the 
only phenomenon. A very interesting case is that of Prof. Lordat, 
which is graphically described by Trousseau. 3 The loss of speech was 
at first complete, but was entirely regained in twelve hours. 

1 The whole subject of cerebral congestion has been well considered by Calmeil, in his 
"Traite des Maladies Inflammatoires du Cerveau." Paris, 1859. 

2 See a memoir by the author, entitled " A Medico-Legal Study of the Case of Daniel 
McFarland," in the Journal of Psychological Medicine for July, 1870; also published 
separately by D. Appleton & Co. New York, 1870. Also a paper on "Morbid Impulse," 
Psychological and Medico-Legal Journal, August, 1874. 

3 " Lectures on Clinical Medicine," etc. Translated by P. Victor Bazire, M. D. Lon- 
don, 1866, p. 219. 



CEREBRAL CONGESTION". 53 

Several similar instances have come under my observation. In a 
case at this time under my charge, the patient, a lawyer, was suddenly 
deprived of all power of speech, after passing several hours in very in- 
tense study. There was a little confusion of ideas, but neither pain nor 
vertigo. There was loss both of the memory of words and of the power 
of so coordinating the muscles of speech as to articulate. There was 
no paralysis anywhere. Recovery was complete in less than six hours. 

In two cases occurring in my own practice, the patients were sud- 
denly rendered aphasic by inhalation of the nitrite of amyl. The 
effect continued for half an hour in one case, and for nearly an hour in 
the other, after all the other phenomena from the amyl had entirely 
disappeared. 

The subject of aphasia will be more fully considered in a subse- 
quent part of this work. 

It is quite probable that certain disturbances of the sensory organs, 
restricted spasmodic actions, and paralyses, illusions, and hallucina- 
tions, intellectual, emotional, and volitional impulses of a morbid char- 
acter, and other abnormal cerebral manifestations, to some of which 
attention has been directed, are the results of localized and quite lim- 
ited congestions of the brain. As already said, however, it would be 
premature to differentiate these with any attempt at exactness till our 
knowledge of the various sensory, motor, and mental centers of the 
brain is more exact than it is at present. 

Third Stage. — This period may be considered as beginning after 
the immediate effects of the paroxysm, whether it has been of the apo- 
plectic, paralytic, convulsive, maniacal, or aphasic form, have passed 
off. It is characterized by feebleness of body and mind, by gastric or 
intestinal derangement, by pain in the head, with transient attacks of 
vertigo, and occasionally by numbness and slight paralysis of one or 
more of the limbs. Many of the symptoms met with in the first stage 
are again found in this. 

But the principal phenomena are those connected with secondary 
lesions, such as inflammation, abscess, softening, and adventitious 
growths of various kinds. These will be considered under their 
proper heads. It must not be forgotten that one circumstance al- 
ways exists, and that is, the proclivity to other paroxysms of some 
one of the fully-developed forms. 

PASSIVE CEREBRAL CONGESTION". 

This condition is the result of causes which increase the amount of 
venous blood in the brain. It is more commonly met with in old per- 
sons and in those of feeble constitution. Women are more frequently 
affected than men. 

Symptoms. First Stage. — As in active cerebral congestion, there 
is a premonitory stage, the symptoms of which are similar to those 



54 DISEASES OF TIIE BRAIN. 

previously described. There is, however, a tendency to stupor, and 
the other phenomena are, in the main, less strongly marked. Vertigo, 
pain, illusions, hallucinations, and delusions, are nevertheless generally 
present at one time or another. But the stupor, or tendency to som- 
nolence, is the most prominent feature, and the sleep, even when com- 
paratively natural, is attended with dreams, unpleasant or even fright- 
ful in character. 

The degree of congestion may be suddenly increased, or, what is a 
more probable sequence, there may be effusion of serum, and then in 
either case the second stage, exhibiting itself as in the apoplectic, the 
paralytic, the convulsive, the soporific, the maniacal, or the aphasic 
form, results. 

The proportion of cases of passive cerebral congestion which pass 
to the second stage is greater than in the active form of the affection, 
and it is accordingly a more serious disease. 

Second Stage, a. The Apoplectic Form. — In this variety the 
onset of the affection is sudden, like that of active cerebral congestion. 
The loss of consciousness is generally complete, the face is red, the 
pupils are dilated and insensible to light, the respiration is stertorous, 
and the faeces and urine may be passed involuntarily. The action 
of the heart is slow and feeble, and the pulse corresponds to these 
facts. Paralysis may be general, or confined to a lateral half of the 
body. 

If sensibility returns, there are pain in the head, vertigo, tinnitus 
aurium, generally some embarrassment in the speech from lingual pa- 
ralysis, and more or less loss of the power of motion in other parts of 
the body. There will also be general or partial anaesthesia. As the 
condition of the patient improves, these symptoms generally disappear. 
Death, however, is not an infrequent sequence. This form of cerebral 
congestion is most common with elderly persons, and appears to be 
particularly apt to attack old women. 

b. The Paralytic Form. — This does not differ essentially from the 
apoplectic form, except that there is no loss of consciousness, the pa- 
ralysis constituting the main symptom. It may be either sudden or 
gradual in its inception. 

c. The Convulsive Form. — This may not differ materially from the 
convulsive form of active congestion, except as regards increased length 
of the fit and prolonged stupor. Generally, however, there is a repeti- 
tion of the seizures, and I am led to believe, from my experience, that 
there is a greater tendency to biting the tongue. Paralysis is a more 
common sequence, and is of longer duration, and the mind appears to 
suffer more seriously and at an earlier period. 

d. The Soporific Form. — The first symptom observed is commonly 
a general numbness and indisposition to muscular exertion. The drow- 
siness, which has probably been present to some extent, increases, and 



CEREBRAL CONGESTION. 55 

soon becomes the most notable feature. At first, it is easy to rouse 
the patient from this stupor, but it gradually becomes more profound 
and overpowering, until at last a persistent comatose condition is 
reached. The faculties of the mind may, in the earlier stages, be ex- 
cited into a moderate degree of activity ; but with the advancing coma 
they are no longer capable of being manifested. The cutaneous sensi- 
bility becomes less and less, the urine dribbles, from paralysis of the 
bladder and its sphincter, and the bowels, if not obstinately constipated, 
allow their contents to pass involuntarily. With these symptoms, the 
pupils are dilated, and, as long as sensibility exists, pain in the head is 
complained of. The faculty of speech is impaired at an early period, 
but, although the tongue is restrained in its movements, there is no 
actual paralysis of this or any other muscle. This condition may last 
for several weeks, and, though recovery occasionally takes place, this is 
never complete. Death is the more usual termination. 

e. The Maniacal Form is not often met with in passive cerebral 
congestion, and, when it is, the delirium, so far from being of a furious 
type, is low. The patient mutters to himself incoherently, and exhibits 
great muscular restlessness, but never attempts to do violence to him- 
self or others. Coma often occurs as a sequence. 

f. The Aphasic Form.— Aphasia without other complication is not 
often met with as a consequence of passive cerebral congestion. Two 
instances only have come under my notice, and in both the development 
was much slower than is usually the case in the active form of the affec- 
tion. In both of these there was disease of the right side of the heart, 
manifested by mitral and tricuspid regurgitation, jugular pulsation, 
great fullness of the veins of the neck and face, and ascites and general 
anasarca. The loss of the idea of language was complete in both cases, 
and persisted for about forty-eight hours. There was no paralysis, 
stupor, or convulsion, and but slight pain. The ophthalmoscope re- 
vealed the existence of great turgescence of the retinal veins, with ve- 
nous pulsation. 

Causes. — The causes of cerebral congestion are : of the active form, 
those influences which are capable of increasing the quantity of arterial 
blood in the brain : of the passive, those which produce a similar effect 
upon the amount of venous blood circulating in the vessels within the 
cranium. The causes of the first category induce activity of circulation, 
those of the second torpidity. 

The causes of active cerebral congestion may either, by their grad- 
ual operation, initiate the premonitory stage, or they may suddenly 
induce the development of this stage into one or other of the varieties 
already described as constituting the second stage. Among them is 
temperature either very high or very low. Thus, the disease is more 
frequent in hot climates than in those of more temperate character, and 
in the summer months than in the spring or autumn. It is, however, 



56 DISEASES OF THE BRAIN. 

more common in very cold than in warm weather. Thus Andral, of 
one hundred and fourteen cases, found that twenty-six occurred in sum- 
mer and fifty in winter. My own experience is to the same effect, as 
will be seen from the following table, which embraces the cases in my 
private practice in the city of New York during a period of five years, 
beginning January, 1865, and ending December, 1870 : 

January 66 July 68 

February 64 August 74 

March 50 September 27 

April 39 October 31 

May 42 November 52 

June 37 December 72 

Total 622 

An examination of this table shows that one hundred and ten cases 
occurred in the autumn months, one hundred and thirty-one in the 
spring, one hundred and seventy-nine in summer, and two hundred and 
two in winter. All my subsequent experience is to the same effect. 

Passive cerebral congestion is very much more frequent in cold 
than in warm weather. 

The direct rays of the sun are capable of producing sudden attacks 
(insolatio), of which congestion is a prominent feature, but which re- 
quire separate consideration ; and it is not uncommon for artisans, 
whose heads are exposed to heat from furnaces, to suffer in a similar 
manner. 

Some authors contend that certain winds increase the liability to 
cerebral congestion. Leuret, quoted by Mosmant, 1 could attribute an 
epidemic of cerebral congestion, which appeared at Charenton, to noth- 
ing but a long-continued wind from the northwest. The supposition 
that atmospheric electricity is a causative influence rests upon nothing 
but hypothesis. 

Unhealthy situations, such as those subject to the influence of ma- 
laria and to noxious emanations of any kind, and which are not well 
ventilated, also predispose to attacks of cerebral cbngestion. 

The ingestion of a large quantity of food into the stomach may 
occasion passive congestion, by the pressure which the distended 
organ makes upon the large veins of the abdomen. Rapid eating, 
even though the quantity of food be moderate, may cause the active 
form of the affection by some influence exerted through the sympa- 
thetic system. 

Sudden and violent physical exertion, especially if made in the 
stooping posture, is very liable to induce cerebral congestion. Child- 
birth is an instance in point, and I have known several cases to be 
caused by severe straining in the water-closet. The constipation of 

1 " Essai sur la Congestion Cerebrale." Paris, 1858. 



CEREBRAL CONGESTION. 57 

the bowels rendering such efforts at defecation necessary is itself pro- 
ductive of the disease. 

A dependent position of the head and constriction of the neck from 
the dress are also, by impeding the return of blood from the head, liable 
to induce congestion of the passive form. 

Certain articles of food and medicine, such as spices, alcoholic 
liquors, opium, belladonna, quinine, etc., act either by augmenting the 
power of the heart, or by their effect on the sympathetic, paralyzing 
the vaso-motor nerves, and thus increasing the caliber of the cerebral 
blood-vessels. In this connection, the influence of the nitrite of amyl, 
when inhaled to increase the quantity of blood in the brain, may be 
cited as an instance of this latter power. 

Tumors in the neck, or in other parts of the body where the return 
of blood from the head may be impeded by their pressure, likewise 
cause congestion. Other causes are to be found in certain diseases, 
as fevers of various kinds, erysipelas, disorders of menstruation, the 
suppression of hemorrhagic or other discharges ; local affections of 
the brain, as embolus, thrombosis, tubercle or apoplectic clots, and 
sympathetically by worms in the intestinal canal, or irritation existing 
in other portions of the system. Hypertrophy of the left side of the 
heart is a common cause of active cerebral congestion ; and any affec- 
tion of the right side of this organ, tending to impede the return of 
the venous blood, is an important factor in giving rise to the passive 
form of the affection under notice. 

But the most influential and common causes of cerebral hyperemia, 
and eventually of congestion, are to be found in long-continued intel- 
lectual exertion, mental anxiety, or sudden, violent, or prolonged emo- 
tional disturbance. It is from the action of such factors that the pre- 
monitory symptoms are generally induced, though they may, especially 
those embraced in the last-named category, immediately develop a 
fully formed attack. The fact that cerebral exercise increases the 
amount of blood in the head is made evident to all of us at times, by 
the distention of the superficial vessels, the suffusion of the eyes, the 
heat and pain which we feel when we have overtasked our brains. 
Cerebral action is always attended with hyperemia, just as is the 
activity of the liver, the kidneys, or other organs. Active cerebral 
congestion is thus induced, and is, within certain limits, perfectly nor- 
mal. But these limits are liable to be exceeded — and, in this active 
period of the world's history, often are — and then the condition de- 
scribed as the first stage of congestion is established. The vessels, from 
continued over-distention, lose their contractility, just as I have said 
does the India-rubber band, used to keep a bundle of letters together, 
when the package is too large, or it has been kept stretched for a 
long time; An additional disturbing force, heat, cold, an overloaded 
stomach, increased mental labor, emotional excitement, or any of 



58 DISEASES OF THE BRAIN. 

the causes mentioned, may suddenly evolve a fully developed par- 
oxysm. 

Emotion acts in a similar manner, though, as has been said, often 
with more suddenness. The emotions of shame, of anger, and others 
cause the face to become red from dilatation of the blood-vessels, and 
a like effect is produced in the vessels within the cranium. If the 
emotion is very strong or lasting, a correspondingly increased hyper- 
semi a results. 

There are certain circumstances which render the action of the 
causes specified more effectual or powerful. These are inherent in 
the individual, and may be classed as predisposing causes. Among 
them are sex, the disease being more common in males ; age, it being 
more frequently met with in middle-aged or old persons ; hereditary 
influence ; hypertrophy of the left ventricle of the heart, by which 
the flow of blood to the head is directly increased ; dilatation of the 
right ventricle, by which its power is diminished, and the return of 
blood from the head impeded ; insufficiency of the auriculo-ventricular 
valves, or constriction at the auricular or ventricular orifices on the 
same side, by which a similar result is produced, and perhaps, though 
this point is by no means established, shortness of the neck. 

Diagnosis. — Cerebral congestion may be confounded with cerebral 
haemorrhage, meningeal haemorrhage, embolism, thrombosis, softening, 
epilepsy, urinaemia, stomachal vertigo, auditory vertigo, and with the 
very opposite condition, cerebral anaemia. From each of these affec- 
tions it is, however, distinguished by well-marked characteristics. 

The premonitory symptoms are not liable to be mistaken for cere- 
bral haemorrhage, but this error may be made as regards the second 
stage. The apoplectic form is, however, distinguished from apoplexy 
due to extravasation, by the fact that in it the loss of intelligence is 
rarely complete, and that, when it is so, the mind is dormant but for a 
few moments ; that sensibility and the power of motion are never alto- 
gether abolished ; that coma, when present, is rarely profound ; that 
the paralysis, when it exists, is seldom limited to one side of the body ; 
by the general absence of stertor, and puffing of the lips and cheeks 
in breathing ; and by the short duration of the symptoms. 

From meningeal haemorrhage, it is discriminated by the comparative 
lightness of the symptoms, and by the fact that they do not progres- 
sively augment in severity or intermit in violence. 

Cerebral congestion and embolism present some features in com- 
mon, and it is therefore occasionally difficult to distinguish them. In 
the former, however, the pulse is slow and the respiration regular and 
deep ; in the latter, the pulse is more rapid, is often irregular, as is also 
the respiration ; in the former, there is increased heat of the head ; in 
the latter, the temperature of this part of the body is unchanged ; in 
cerebral congestion the symptoms are transient ; in embolism they are 



CEREBRAL CONGESTION. 59 

more lasting ; in the former there is often a distinct premonitory 
stage ; in the latter, the attack always takes place without a moment's 
warning. In the former, though there may be cardiac difficulties, they 
are different from those predisposing to embolism, which are consecu- 
tive to endocarditis — generally rheumatic — and which implicate the 
semi-lunar or mitral valves, and in the fact that recovery from an at- 
tack of cerebral congestion is generally complete, which is rarely the 
case in embolism. 

From thrombosis, cerebral congestion is diagnosticated by the cir- 
cumstances that in the former the progress of the disease is slow, that 
there is usually well-marked paralysis from the beginning ; that the phe- 
nomena indicating mental disturbance are more strongly pronounced ; 
that the articulation and memory for words are more permanently af- 
fected ; and, notwithstanding occasional remissions, by the persistency 
and gradual advance of the symptoms. 

In softening there are often a sudden loss of consciousness, persist- 
ent hemiplegia, and death in a few days. Again, there is delirium 
without paralysis or convulsions, and in other cases there is a gradual 
accession of the symptoms. This latter is the only form liable to be 
mistaken for cerebral congestion. It is attended with headache, feeble- 
ness of intellect, and a gradually advancing paralysis generally, begin- 
ning in one of the lower extremities, and extending to the whole of 
one side of the body. The speech is always seriously impaired, and 
the mental disorder is of a far graver character than that due to cere- 
bral congestion. The gradual advance of the affection to a fatal ter- 
mination is also a characteristic circumstance. 

With urinsemia, cerebral congestion may be confounded, if only tbe 
more obvious head symptoms be taken into consideration. The his- 
tory of the case and full inquiry will always, however, enable the proper 
discrimination to be made. Thus, in uringemia the existence of kidney 
disease, as evidenced by a chemical and microscopical examination of 
the urine, the anasarca of the face or limbs, and the repeated attacks 
of convulsions and coma, will be sufficient diagnostic marks. 

From epilepsy, cerebral congestion is distinguished by the fact that 
the former is not preceded by the group of symptoms constituting the 
first stage of congestion ; that the congestion of the vessels of the face 
and neck is preceded by a death-like paleness ; that an aura is often 
present ; that there may be a peculiar cry ; that the patient does not 
stagger and fall slowly to the ground, but drops as if knocked down 
by a severe blow ; and that the tongue is frequently bitten. The re- 
verse is the case as regards all these phenomena in cerebral congestion. 
Nevertheless, so accurate and experienced an observer as Trousseau, 
in his clinical lecture on "Apoplectiform Cerebral Congestion in its Re- 
lations to Epilepsy and Eclampsia," * confounds the two conditions. 
1 " Clinique M6dicale," tome ii., p. 56. Also Bazire's Translation, London, 1866, p. 19. 



GO DISEASES OF THE BRAIN. 

Trousseau's views on this subject do not, however, appear to be accepted 
by any large number of medical authorities. Epileptic vertigo is, as 
will be shown at a proper place, a very different affection from any 
form of cerebral congestion, and is not likely to be confounded with 
it. Epileptic mania has, likewise, very few points in common with the 
disease under consideration. 

In stomachal vertigo the attacks of dizziness are often severe, but 
they are clearly associated with gastric derangement, and only occur 
while the stomach is digesting its contents. Other symptoms of dys- 
pepsia will also be noticed, while the mental and physical disturbances, 
which constitute so prominent a feature of cerebral congestion, are ab- 
sent. The distinction, however, is not always made. 

In auditory vertigo, or Meniere's disease, the dizziness is accompa- 
nied with aural troubles, such as deafness and tinnitus ; the face is pale ; 
and there is almost invariably vomiting, or at least intense nausea. 
Moreover, when there is loss of consciousness, the premonitory symp- 
toms are not such as precede the second stage of cerebral congestion, 
but are connected with the function of audition. 

From cerebral anaemia, the first stage of congestion is frequently not 
clearly distinguished, and I have seen several cases in which patients 
had been treated for the one condition when the other was indubitably 
present. In both there are headache, sense of constriction, vertigo, 
noises in the ears, numbness, mental confusion, loss of memory, inapti- 
tude for labor of any kind, and at times loss of consciousness. But in 
anaemia the face is not flushed, the carotid and temporal arteries do not 
throb with violence ; the pulse is quick, feeble, and irregular, the res- 
piration is hurried, the pupils are dilated, there are bellows murmurs 
at the base of the heart and in the veins of the neck, and the general 
aspect of the patient is not of that rugged appearance so generally 
associated with cerebral congestion. In the syncope of cerebral anae- 
mia, the paleness of the face, coldness of the skin, and feebleness of 
the heart's action, will serve to draw the line between it and the apo- 
plectic form of congestion. The ophthalmoscope will at all stages 
prove of great value in the diagnosis. 

Prognosis. — The prognosis is materially modified, according to the 
stage of the disease present when the patient is seen, and the form of 
attack from which he may be suffering. Active cerebral congestion is 
a more favorable type than the passive. If the affection has not gone 
beyond the first stage, a fortunate issue may safely be predicted under 
the use of suitable medical treatment ; but, if, through neglect or im- 
proper treatment, or indiscretion on the part of the patient, the disease 
becomes fully developed, the prognosis is much more grave. I have 
never known a death to take place in any patient from this disease 
during the premonitory stage. The apoplectic and soporific forms are 
the most grave, and the prognosis is rendered more unfavorable with 



CEREBRAL CONGESTION. 61 

each attack. The epileptic form is ordinarily not dangerous to life, 
nor is the paralytic, maniacal, or the aphasic, except in old persons. 
Occasionally, however, even in young and robust patients, death en- 
sues during the paroxysms of these forms. 

The liability to secondary lesions, such as softening, cerebritis, haem- 
orrhage, aneurisms, general paralysis, etc., must be taken into account 
when forming a prognosis. The more frequent the paroxysms of any 
form, the greater the ri^k of some such finality. 

The habits of the patient are also important elements in forming 
an opinion in regard to the ultimate result. If these are bad, and are 
persisted in, the probability is that no treatment will be of much avail 
in preventing a recurrence. Moreover, by such a condition of the brain 
as the excessive use of alcohol, inordinate mental exertion, or contin- 
ual emotional excitement induces, the chance of escaping some sec- 
ondary morbid process is very much lessened. 

Of the one hundred and seven fully developed cases which have 
been under my observation during the past eight years, there were 
eighteen deaths ; seven from the apoplectic form, all after repeated 
attacks ; three from the maniacal, one of which was that of a young 
man about thirty years of age ; and seven from secondary lesions. Of 
these latter, four were from softening, one from cerebritis, one from 
haemorrhage, and one from general paralysis. 

Morbid Anatomy. — There are certain appearances seen in the brains 
of those who have died of cerebral congestion which are characteristic, 
although it must be confessed that some or all of them are occasionally 
absent. These are : 

An increased size of the capillaries and large blood-vessels, both of 
the brain and the pia mater. It thus happens that, when a section of 
the brain is made, the red points ordinarily seen are larger and more 
numerous than usual, and that the pia mater presents in spots, or 
throughout its extent, a red or rose-colored appearance. 

The white matter of the brain is increased in consistence and den- 
sity, and the gray matter is red, or even violet in hue. 

There is sometimes a large quantity of subarachnoidean effusion ; 
the ventricles may contain an excessive amount of fluid, and the cho- 
roid plexuses are often enlarged. 

If there have been repeated attacks of cerebral congestion, it is 
not unusual to find, by microscopical examination, little granules of 
hsematin in contact with the blood-vessels. The same means of explo- 
ration shows the minuter capillaries to be more than naturally tortuous, 
and to have little aneurismal swellings. These may or may not involve 
the whole circumference of the vessel. Their presence and import 
were first pointed out by Laborde. 1 

1 "La ramollissement et congestion du cerveau principalement considered chez de 
vieillard." Paris, 1866. 



62 DISEASES OF THE BRALY. 

On making a transverse section of the hemisphere, a cribriform 
appearance is seen, if the patient has repeatedly suffered from attacks 
of cerebral congestion, and especially if he be advanced in years. This 
is due to the presence of numerous little holes with sharply-defined 
margins. The brain-tissue bounding these is generally without mate- 
rial change, either in color or consistence. This condition, called by 
Durand-Fardel, 1 to whom the credit of first describing it is usually 
given, " Petat crible," is supposed to be due to the fact that the vessels 
have been so distended during life as to press with increased force 
upon the perivascular tissue, and that, shrinking after death, they no 
longer fill their former space, which remains empty. Calmeil 2 was 
the first to notice this condition. He has very often found, in maniacs, 
the white substance rendered cribriform by vessels distended with 
blood, sometimes empty, but always greatly dilated. This state, al- 
though frequently met with in congestion, is not uncommon in other 
pathological conditions, such as the several forms of softening, of 
which, however, congestion is often the first stage. 

Durand-Fardel 3 calls attention to the fact that, on making sections 
of the medullary substance of the cerebrum, it is not uncommon to find 
in cases of congestion rose-colored patches scattered throughout its 
substance. On examining these with a lens, they are seen to consist of 
a large number of delicate vessels partially injected. I have never wit- 
nessed this appearance, except in one instance, nor is it noticed by au- 
thors on the subject generally. 

If the congestion has been severe or long continued, the convolutions 
may be to a considerable extent obliterated by the compression of the 
brain against the internal wall of the cranium. At the same time, the 
membranes of the brain are rendered dry and viscous from the pressure 
to which they have been subjected. 

In passive congestion the sinuses of the dura mater are the chief 
seats of vascular turgescence ; the veins generally are distended, and 
there is ordinarily a greater amount of serous effusion in the subarach- 
noid space than in the active variety of the disease. 

Pathology. — It is almost useless at this day to discuss the question 
of the possibility of the quantity of blood in the brain being subject to 
variation. Still, it may be interesting to recall briefly the facts which 
establish the affirmative in the matter. 

In the cases of infants, in whom the anterior f ontanelle is still open, 
the scalp is seen to be elevated above the level of the skull when the 
head is dependent, and depressed when the head is elevated. 

The same fact is observed in persons who have suffered injury of the 

1 " Trait e pratique des maladies des vieillards." Paris, 1854, and deuxieme edition, 
1873. 

2 " De la paralysie consideree chez les alienes," etc. Paris, 1826. 

3 Op. cit., Paris, 1873, p. 21. 



CEREBRAL CONGESTION. 63 

skull, involving the loss of a portion of its substance. During strong 
emotional excitement, or the action of any cause capable of increasing 
the force of the circulation, the scalp is elevated. From the action of 
opposite causes it is depressed. Both in infants and in persons who 
have received injuries such as those cited, the scalp is seen to be de- 
pressed during sleep, and to rise as soon as the individual awakes. 

A dependent position of the head causes a sensation of fullness, or 
even pain, and blood may flow from the nostrils. The eyes are observed 
to be " bloodshot," and the countenance indicates congestion. A tu- 
mor, a ligature, or any other cause capable of exerting pressure on the 
jugular veins, will produce like effects. Ophthalmoscopic examination 
under such circumstances shows the veins of the retina to be enlarged, 
indicating that an obstruction exists to the return of blood through the 
sinuses and veins within the cranium. Post-mortem examination of 
persons dying, who, during life, have suffered interruption to the per- 
fect return of blood from the head, reveals the existence of intracranial 
congestion. Animals, subjected to experiments calculated to act in the 
manner stated, are after death found to have congested brains. 

In animals bled to death the brain is found anaemic to an extreme 
degree. 

Direct experiment still more positively establishes the fact under 
consideration. If a portion of the skull of an animal be removed, and 
the aperture be then securely closed with a watch-glass, the vessels will 
be seen to enlarge and contract according to the cause brought into 
action, and the brain will be correspondingly elevated or depressed. 

By means of an instrument, devised, independently of each other, by 
Dr. S. Weir Mitchell and myself, the degree of pressure within the cra- 
nium can be accurately measured. It is thus seen that the quantity of 
blood circulating in the brain undergoes material variation. 1 

The anatomical arrangement of the blood-vessels of the cerebral tis- 
sue is such as to admit of an enlargement of their calibre without neces- 
sarily subjecting the perivascular substance to pressure. Robin 2 dis- 
covered the existence of sheaths around these vessels, and his observa- 
tions were subsequently confirmed by His, 3 who ascertained that the 
same arrangement exists in the spinal cord. According to His, " Fine 
transverse sections of a hardened brain, having its vessels injected or 
otherwise, show that all the blood-vessels, arteries, veins, and even 
capillaries, are surrounded by a clear space, broadest in the case of the 

1 For a more complete argument on the subject, and for a statement in detail of the 
experiments of Mr. Durham and myself on this point, the reader is referred to the author's 
monograph, "Sleep and its Derangements." Philadelphia: J. B. Lippincott & Co., 1870. 
The cephalo-hsemometer referred to in the text is described in that work (Appendix), and 
also in the introduction to this treatise. 

2 Journal de la physiologie de Vhomme et des animaicx, 1859, p. 527. 

3 "Zeitschrift fur Wissenschaftliche Zoologie," 1865, B. xv., quoted in the Journal of 
Anatomy and Physiology. Translation by Dr. Bastian. 



64 DISEASES OF THE. BRAIN. 

larger vessels, but in all cases quite sharply defined externally. In 
transverse sections the vessels are seen to be surrounded by a ring-like 
space, and in parallel sections the space is seen on each side of the 
trunk of the vessel, and follows it in all its ramifications." 

These perivascular canals are lined by a hyaline membrane, and are 
capable of being injected, and, in cases of chronic congestion, may be- 
come permanently enlarged, so as to cause the appearance referred to 
under the heading of morbid anatomy. 

The pathology of the subject receives further elucidation from a con- 
sideration of the causes capable of giving rise to cerebral congestion, 
and which have been already mentioned in detail. 

Treatment. — Recollecting the two grand forms of cerebral conges- 
tion, the principles which should guide us in treatment will be clearly 
apparent. In the active type of the disease, the force of the cerebral 
circulation and the quantity of blood in the blood-vessels of the brain 
are to be lessened ; in the passive variety, the force of the circulation 
is to be increased, and at the same time the accumulation of blood in 
the veins to be diminished. In the active form of this affection, the 
abstraction of blood from the arm was formerly very generally practised, 
but is now rarely perfomed. I have never seen a case in which it was 
required. Local bleeding is more generally applicable, and a few cups 
to the nape of the neck will often afford marked relief. Leeches to the 
temples are also useful, though they are preferably applied just inside 
the nostrils. I have many times witnessed the most satisfactory results 
from a couple of leeches thus used, and from accidental nasal haemor- 
rhage. 

The application of the actual cautery to the nape of the neck is 
also a measure of value, especially in the earlier stages. It is prefer- 
able, I think, to any other form of counter-irritation, and, when prop- 
erly done, is not at all painful. It seems to have a positive and, in 
some cases, an immediate influence in diminishing the calibre of the 
cerebral arteries. 

Cold is another very useful agent in the treatment. It may be ap- 
plied to the nape of the neck, or directly to the cranium, either as very 
cold water or in the form of ice. 

The advantages of position should also be brought to bear. The 
head should be kept elevated, especially during sleep, and no severe 
muscular exertion should be taken while stooping. 

The clothing should be kept loose about the neck. As a derivative, 
a mustard-plaster applied to the epigastrium is often of service ; and 
the same may be said of warm or even hot water to the feet. Blis- 
ters I rarely employ, though I have occasionally done so with ad- 
vantage. 

The constant galvanic current possesses the power of contracting 
the cerebral blood-vessels, when so used as to stimulate the sympathetic 



CEREBRAL CONGESTION. G5 

nerve, For this purpose, one pole should be placed over this nerve in 
the neck, and the other on the back of the neck, as low down as the 
seventh cervical vertebra. The current from about fifteen Smee's cells 
is sufficient, and it should not be allowed to act for more than two 
minutes. If extreme vertigo be produced, the number of cells should 
be lessened. This property of the primary current was first pointed out 
by Bernard, Waller, and Budge, but its demonstration by the ophthal- 
moscope was first made by myself. Observation with this instrument, 
while the current is acting, shows that the vessels of the retina con- 
tract, and hence there can be no doubt that the result is produced 
upon those of the brain. A similar effect is caused by passing the 
current directly through the brain, the poles being applied to the 
mastoid processes. A slight feeling of vertigo follows both when the 
circuit is closed and opened. The good effects of this practice are well 
marked, a few applications being often sufficient to abolish the vertigo 
and unpleasant feelings in the head, and to restore mental and physical 
activity. 

Of internal remedies the number is not large, and those which it is 
advisable to employ are generally effectual, with or without the exter- 
nal measures mentioned, in entirely relieving the patient. 

First among these must be placed the bromide of potassium. Sev- 
eral years ago I pointed out the value of this medicine, and explained 
the rationale of its action. As others have since claimed the discovery 
as their own, I hope I may be excused for quoting the following pas- 
eage from a memoir upon an analogous subject, 1 in which the action 
of the bromide is clearly indicated : 

" Bromide of potassium can almost always be used with advantage 
to diminish the amount of blood in the brain, and to allay any excite- 
ment of the nervous system that may be present in the sthenic form of 
insomnia. That the first -named of these effects follows its use, I have 
recently ascertained by experiments upon living animals, the details of 
which will be given hereafter. Suffice it now to say that I have 
administered it to dogs whose brains have been exposed to view by 
trephining the skull, and that I have invariably found it to lessen the 
quantity of blood circulating within the cranium, and to produce a 
shrinking of the brain from this cause. Moreover, we have only to 
observe its effects upon the human subject, to be convinced that this 
is one of the most important results of its employment. The flushed 
face, the throbbing of the carotids and temporals, the suffusion of the 
eyes, the feeling of fullness in the head, all disappear as if by magic 
under its use. It may be given in doses of from ten to thirty grains, 
the latter quantity being seldom required, but may be taken with 
perfect safety in severe cases." 

Since then, experiments with the cephalo-ha?mometer and ophthal- 

1 " On Sleep and Insomnia." New York Medical Journal, June, 1865, p. 203. 
6 



66 DISEASES OF THE BRAIN. 

moscope have abundantly confirmed these views, and more extensive 
experience in the treatment of cerebral congestion has placed the 
matter beyond the possibility of a doubt. Other observers have also 
confirmed the opinions here expressed. 

The prescription which I often employ consists of bromide of 
potassium, § j ; water, J iv ; of this a teaspoonful is taken three 
times a day in a little water. Occasionally the bromide is in- 
creased to 5 i ss > anc l sometimes a saturated solution — which contains 
grs. xxx to 3 j — is used. I continue the medicine till drowsiness, a 
slight feeling of weakness in the legs, and contraction of the blood- 
vessels of the retina — detected' by the ophthalmoscope — are pro- 
duced. The more prominent head -symptoms generally disappear 
in four or five days, and the results above mentioned ensue in about 
ten days. 

Latterly I have used the bromide of sodium in corresponding 
doses instead of the bromide of potassium. It is more pleasant to 
the taste, and does not' cause so much constitutional disturbance as 
sometimes follows the administration of the bromide of potassium in 
large doses. 

The bromide of calcium is also well adapted to the treatment of 
cases of active cerebral congestion, and has the advantage over the 
other bromides of acting more promptly. 

As is well kriown, ergot possesses the property of constricting the 
organic muscular fibre. This property has for several years past led 
to its successful application to the treatment of those diseases of the 
spinal cord in which it is desirable to lessen the amount of blood in 
its vessels. It is only lately, however, that this agent has been em- 
ployed in similar affections of the brain. From my own experience, 
as well as from a consideration of the investigations of others, I am 
entirely satisfied that ergot does contract the cerebral vessels, and 
hence that it diminishes the quantity of intracranial blood. Among 
the first, if not the very first, to call attention to this property was 
Dr. Charles Aldridge, 1 who noticed that after the administration of 
a full dose he found it to cause " contraction of the arteries of the 
retina and loss of the capillary tint of the disk." My own observa- 
tions are entirely in accord with these results. I have repeatedly 
found a single dose of two drachms of the fluid extract produce a 
decided diminution in the calibre of the retinal arteries, and a marked 
pallor of the disk. 

In addition, some recent experiments which I have performed upon 
dogs, in which the ergot was administered hypodermically in doses of 
from one to three drachms of the fluid extract, after the animals had 
been trephined and the cephalo-hsemometer inserted into the opening 

1 "West Riding Lunatic Asylum Reports," vol. i., p. 71, London, 1871; also vol. 
iii., p. 230. 



CEREBRAL CONGESTION. 67 

in the skull, showed from the falling in the tube that the intracranial 
pressure was notably lessened. 

Applying these facts clinically, it is found that ergot is of very 
great value in the treatment of active cerebral congestion in all its 
forms, but especially in the first or hyperamiic stage. I am in the 
habit of giving drachm-doses of the fluid extract three times a day, in 
combination with some one of the bromides. An excellent formula 
is sodii bromidi, f j ; ergotse ext. fluidi, § iv. M. ft. sol. Dose, a 
teaspoonful three times a day. 

Or the ergot may be given alone, either in the form of the fluid 
extract, or of the ergotin of Beaujon, which is simply a solid extract. 
This latter is made into pills of from three to five, or even ten grains 
each, one of which should be administered three times a day. 

In the first or hyperaemic stage, and especially where the pain in 
the head has been a prominent feature, I have frequently seen prompt 
relief of the cerebral distress from the administration of ten or fifteen 
grains of phenacetine. 

At the end of about ten days it will generally be found that under 
this treatment all symptoms of congestion — subjective and object- 
ive — have disappeared, leaving a little debility and mental depres- 
sion. It then becomes expedient to give tonics and restoratives, 
and those w r bich have a special action on the nervous system are to 
be preferred. Among them, strychnia, phosphorus, and cod-liver oil 
stand first. 

Strychnia may be advantageously administered in conjunction 
with iron and quinine dissolved in dilute phosphoric acid, as in the 
following formula : Strychnise sul., gr. j ; ferri pyrophosphatis, qui- 
niae sul., aa 3 j ; acid, phosp. dil., zingiberis syrupi, aa § ij. M. ft. 
mist. Dose, a teaspoonful three times a day in a little water. I pre- 
fer this extemporaneous prescription to any of the syrups or elixirs 
with like ingredients. If for any reason the iron and quinine are 
not indicated, the strychnia can be given alone with the dilute phos- 
phoric acid. 

The eucalyptus, in the form of the fluid extract, has certainly 
in my hands been productive of excellent results in the treatment 
of the hypersemic stage of cerebral congestion. This has been espe- 
cially the case in those instances in which a malarious influence was 
present, but in which quinia could not have been given without run- 
ning the risk of still further adding to the quantity of intracra- 
nial blood. An ounce of the bromide of sodium may be dissolved 
in four ounces of the fluid extract, and a teaspoonful taken throe 
times a day. 

Hydrobromic acid is of no service in the treatment of cerebral 
congestion, except as a solvent for the sulphate of quinia, the injurious 
effects of which upon the brain it modifies or prevents. A drachm 



68 DISEASES OF THE BRAIN. 

of Fothergill's solution will counteract the congestive tendency of 
about two grains of the sulphate of quinia. It may in some cases be 
advantageously substituted for the dilute phosphoric acid of the for- 
mula just given. 

Phosphorus almost always acts well in such cases as those under 
consideration. It may be given in the form of the phosphorated oil, 
as in the following formula : $ . Olei phosphorat., § ss ; mucil. aca- 
cias, 1 j ; olei bergamii, gtt. xl. M. ft. emulsion. Dose, gtt. xv. three 
times a day. 

A very elegant preparation of phosphorus is the phosphide of zinc. 
The chemical formula of this substance is Zn 3 P, and consequently a 
grain represents a little more than one-seventh of a grain of phos- 
phorus. The proper dose, therefore, is about the tenth of a grain. I 
usually prescribe it in cerebral congestion, according to the following 
prescription : $. Zinci phosphidi, grs. iij ; rosar. conserv., q. s. M. 
ft. in pil. no. xxx. Dose, one three times a day. Instead of the con- 
serve of roses, grs. x of the extract of nux vomica may be substituted 
if strychnia is not being administered in some other form. 

Another very useful form for administering phosphorus is the 
phosphorated resin, which contains four per cent, of phosphorus, thor- 
oughly rubbed up with ninety-six per cent, of resin. This is made 
into pills with conserve of roses, or some other excipient. The dose 
is about half a grain, containing the one-fiftieth of a grain of phos- 
phorus. 

Latterly I have made much use of arsenious acid in cerebral con- 
gestion, especially in cases which have been the result of mental exer- 
tion or anxiety. Its action is certainly preferable to that of Fowler's 
solution. It should be given in doses of about the fiftieth of a grain, 
and after eating, and should be continued for several weeks. Lisle ' 
administers it in the quantity of from a fourth to the third of a grain 
daily, and there is no doubt that it may be given to this extent with- 
out danger. I have never, however, unless there was manifest insan- 
ity, used it in these doses. 

In those cases in which there are dyspeptic symptoms — and they 
constitute the majority — the administration of pepsin and powdered 
charcoal with each meal will be of decided benefit ; and in such cases 
bismuth is often of great service. 

Such is the treatment I have found to be most advantageous in 
active cerebral congestion, and I rarely have occasion to supplement it 
with other measures, unless some special indication is to be fulfilled. 
Thus, if the bowels are constipated, a mild purgative may be given, or 
preferably an enema of warm water or olive-oil ; or, if the urine is 
scanty and high-colored, saline diuretics are useful. 

1 " Du traitement de la congestion cerebrale et de la folie avec congestion et halluci- 
nations par l'acide aresenieux." Paris, 1871. 



CEREBRAL CONGESTION. 69 

In the passive form of the disease it is sometimes advisable to give 
stimulants, which may be done from the first in conjunction with the 
bromide of potassium, sodium, or calcium, with ergot. Alcohol in 
some form is to be preferred when it is well borne, though carbonate 
of ammonia is sometimes a useful substitute. In several cases of pas- 
sive cerebral congestion in old people, and in one instance occurring 
in the person of a very prominent elderly gentleman of this city, I de- 
rived satisfactory results from sulphuric ether inhaled from a handker- 
chief to the extent of a teaspoonful several times a day. The pain, 
constriction, vertigo, numbness, wakefulness, and inability to exert the 
mind, were lessened with every dose, and finally entirely disappeared. 
Ether may likewise be given by the stomach — gtt. xv several times 
daily — in case the inhalation is contra-indicated from any cause. 

Of course, any influence capable of interfering with the due return 
of blood from the head should be counteracted at once. 

In the two cases of aphasic cerebral congestion of the passive form, 
to which reference has been made, I derived the most signal benefit 
from the use of infusion of digitalis in tablespoonful-doses adminis- 
tered every four hours. 

Hygienic treatment should in both types of the disease be persist- 
ently carried out. The food should be nutritious, digestible, and ample, 
though not excessive in quantity. Alcohol and tobacco, if used habit- 
ually by the patient, should be restricted to moderate limits ; I have 
never seen the latter do harm unless used to excess. Tea and coffee 
may safely be left to the patient's own inclinations and experience. 
I believe more harm is done by suddenly breaking off a habit, even 
though it be somewhat injurious, than by tolerating it within due 
bounds. Exercise in the open air — walking, horseback-riding, or driv- 
ing — is always beneficial. The same cannot be said of gymnastic con- 
tortions, which, to make them worse, are usually performed in hot 
rooms. Bathing daily and subsequent friction with a tape towel are 
exceedingly useful in determining blood to the surface of the body. 
The Turkish bath cannot be too highly commended, and douches to 
the nape of the neck, alternately hot and cold, in which the water is 
thrown with force and from a distance of ten or fifteen feet, are highly 
advantageous. 

But, above all, those persons who have brought on the disorder by 
inordinate mental exertion or anxiety must consent to use their brains 
in a rational manner if they wish to recover or to avoid future attacks. 
They have received a warning, and, if they do not heed it, sooner or 
later other diseases, more difficult if not impossible of cure, will make 
their appearance. 

But it is not always the case that the most positive advice on this 
point is followed. Men who would readily see the impropriety of walk- 
ing three or four miles while suffering with an inflamed knee-joint, 



70 DISEASES OF THE BRAIN. 

do not hesitate to exert a disordered brain to the extreme limit of its 
power. It is impossible that the action of a brain thus affected can be 
such as to evoke sound and healthy thoughts. It is not to be wondered 
at, therefore, that the subjects of cerebral congestion who insist upon 
attending to their vocations, and' on concocting schemes for obtaining 
wealth or fame, should perpetrate acts which result in the loss of for- 
tune, or the acquisition of a reputation far different from that sought. 
The cause of cerebral congestion, whatever it be, must, if prac- 
ticable, be removed, and it must continue removed. 



CHAPTER II. 

CEREBRAL ANAEMIA. 



In cerebral anaemia the quantity of blood in the brain is either 
reduced below the normal standard, or the quality of the circulating 
fluid is impoverished. The first-named condition is due either to direct 
loss of blood, to deficient action of the heart, to impaired nutrition, or 
to some cause preventing the due access of blood to the brain ; the 
second to disease of some organ concerned in haematosis or to a gen- 
eral cachexia. The two states very often coexist, and they may prop- 
erly be considered together. 

Symptoms. — In cerebral anaemia suddenly induced from profuse 
haemorrhage, the most prominent symptom is syncope. Vertigo is 
generally an attendant, and there are paleness of the features and 
coldness of the extremities. The pulse is frequent, thread-like, and 
weak. The respiration is feeble and accelerated. 

But, when the accession is more gradual, headache is very generally 
present. It may be, and usually is, confined to a limited portion of 
the head, sometimes to a spot not larger than the point of the finger. 
A feeling of constriction, especially across the brows, is complained of, 
and the vertigo, notably increased on rising from' the recumbent post- 
ure, is as troublesome a feature as in the worst attacks of cerebral con- 
gestion. There is ringing in the ears, and loud noises are not only 
painful but are exceedingly irritating to the nervous system. The 
pupils are largely dilated, and are sluggish, contracting slowly and 
but little on exposure to a strong light. These phenomena may be 
restricted to one eye, a circumstance which generally occasions needless 
alarm on the part of the patient. The retinae are extremely sensitive, 
and hence ophthalmoscopic examination is painful. When employed, 
the vessels at the fundus of the eye are seen to be small and straight, 
and the choroid is paler than is normal. 

Owing to paresis of the ocular muscles — a very common condition 



CEREBRAL ANAEMIA. 71 

in cases of cerebral anaemia — the attempt to use the eyes, as, for in- 
stance, in reading, produces pain in them and in the head. In many- 
cases the effort of three or four minutes causes very great uneasiness. 

The complexion is pale, the lips almost colorless, or else redder than 
in health. The skin is cold and clammy. 

Nausea and vomiting are present in extreme cases, and convulsions 
of an epileptic character may occur. In the rapidly-developed form of 
the disease, caused by sudden and great loss of blood, they are always 
present, and in the milder and more gradual variety they are occasion- 
ally seen, feebleness of muscular power is always met with, and there 
may be general or partial paralysis, with the usual derangements of 
sensibility indicative of anaesthesia, such as coldness, formication, and 
"pins and needles." 

The mind, of course, participates in the general disorder. In ex- 
treme cases, due to active hemorrhage, the patient is completely insen- 
sible. In less severe forms there may be all the gradations from low 
delirium to great mental irritability, or a condition of intellectual lassi- 
tude approaching dementia. 

Hallucinations and illusions are common in the slowly-developed 
forms of cerebral anaemia, and may affect any one or all of the senses. 
Those of sight and hearing are, however, more prominent. In the case 
of a young lady under my care, and whose only marked disorder was 
that under consideration, the hallucination that she saw a black man 
was almost constantly present. At times she conversed with this im- 
aginary being, told him not to trouble her, that she no longer feared 
him, etc. She believed firmly in his presence, and hence had a delu- 
sion. 

In all cases of cerebral anaemia there is more or less drowsiness, 
from the profound syncope of the rapid form to the rather agreeable 
languor present in slight cases. In instances of medium severity, the 
patient readily falls asleep in the sitting posture ; but recumbency in- 
duces wakefulness, from the fact that the quantity of blood in the 
brain is thereby suddenly increased above the habitual standard, and 
a state of comparative hyperaemia is thus induced. I have, in another 
place, 1 called attention to this form of insomnia, and adduced several 
cases in illustration. 

Examination of the heart by auscultation reveals the existence of 
bellows-murmurs, both systolic and diastolic. They are heard more 
loudly at the base of the heart. There are also very generally venous 
murmurs, which are heard most distinctly in the jugular veins, espe- 
cially when the head is turned toward the opposite side. Arterial 
murmurs may also occasionally be perceived. 

These sounds are sometimes heard by the patient, and are then ex- 
ceedingly annoying. I have had under my charge patients suffering 
1 " Sleep and its Derangements." 



72 DISEASES OF THE BRAIN. 

from cerebral anaemia, who constantly heard a sound originating ap- 
parently in the head, and which, as they described it, resembled that 
caused by a large shell placed in the ear. That these murmurs are 
anaemic, is shown by the fact that they disappear under appropriate 
treatment. 

Cerebral anaemia may be of such intensity and be so suddenly de- 
veloped as to cause almost instant death. Many cases are on record 
of patients having died with symptoms of apoplexy, and in whom post- 
mortem examination has shown the blood-vessels of the brain to be 
empty, and the brain itself pale and exsanguined. 

Paralysis of various forms may likewise result from this condition. 
Sometimes there is hemiplegia, at others paraplegia ; again a single 
muscle or a group of muscles may be affected, and it may even happen 
that a general state of paralysis may exist. I have frequently seen a 
single muscle of the eyeball alone involved, and upon one occasion 
witnessed the loss of muscular power confined to one side of the face 
in the person of a lady whose brain was evidently very anaemic. 

Gintrac ' cites the following interesting cases communicated to him 
by Dr. Hirigoyen : 

" A young girl twenty years old, affected with amenorrhoea, con- 
sulted a midwife, who bled her, attributing her trouble to cerebral 
plethora. She had hardly lost two hundred grammes of blood when 
hemiplegia supervened. Iron and tonics entirely dissipated this con- 
dition. 

"A young woman, twenty-five years old, was subject to a severe 
epigastric pain, that had been several times relieved by bloodletting. 
She was thin, pale, and nervous. Nevertheless, a vein was again 
opened, but only about one hundred and fifty grammes of blood were 
taken. Notwithstanding this prudence, a syncope ensued while the 
arm was being tied up, and there were some convulsive movements. 
After two or three minutes the patient recovered her senses, but was 
found to be entirely hemiplegic on the left side, and to have some 
difficulty of speech. Recourse was had to Hoffman's anodyne, vale- 
rian, and appropriate food, and at the end of thirty-six hours she was 
relieved." 

A form of cerebral anaemia met with in young children is of great 
importance, from the fact of its liability to be confounded with an- 
other far more dangerous affection, almost its opposite. This was first 
clearly described by Dr. Gooch, 2 although previously noticed by other 
observers. In children suffering from this affection, the symptoms, so 
far as they are noticeable, are similar to those present in the anaemia 

1 " Traite theorique et pratique des maladies de l'appareil nerveux." Tome premier, 
Paris, 1869, p. 548. 

2 " On Some of the most Important Diseases peculiar to Women ; with Other Papers." 
New Sydenham Society Publication. London, 1859, p. 179. 



CEREBRAL ANAEMIA. 73 

of adults. The drowsiness is well marked, the head is cool, the pulse 
is small and weak, the features are pinched, the pupils large and in- 
sensible to light, and the fontanelle, if still open, has the scalp cover- 
ing it depressed. After death, the vessels of the brain are found to be 
almost empty, and the ventricles distended with fluid. From its re- 
semblance in some respects to hydrocephalus or tubercular meningitis, 
this affection was called by Dr. Marshall Hall hydrocephaloid. The 
distinction, however, is so well defined, that none but the most igno- 
rant or superficial observers would fail to recognize it. 

In some cases of cerebral anaemia a tendency to melancholia exists, 
and positive insanity may eventually result. In most instances of the 
disease there is mental depression, with a strong predisposition to the 
production of hypochondria. 

Causes. — Haemorrhage or other exhausting discharge ranks first 
among the causes of cerebral anaemia. I have known several severe 
cases induced by epistaxis, and one by the continued loss of blood 
from leech-bites. Hemorrhoidal bleeding has also caused it in my 
experience. No influence of the kind is, however, more common than 
uterine bleeding, such as occurs before, during, or after labor, from 
miscarriages and abortions, especially if they are frequently repeated, 
and from excessive menstrual discharge. 

Chronic dysentery and diarrhoea, malarial and other fevers, the 
rheumatic, strumous, and cancerous diatheses, diseases of the bones 
and joints, and long-continued purulent discharges, are likewise causes 
of cerebral anaemia. 

I have several times seen the affection apparently caused by con- 
gestion of internal organs. Niemeyer, referring to this possibility, 
cites the fact that it may follow the use of Jounod's boot. At the 
present time, when this appliance is variously modified and extended 
beyond its legitimate use by itinerant quacks, it is well to call special 
attention to this liability. Several cases in point have come under my 
observation, and in one, a young lady suffering from epilepsy with 
cerebral anaemia, whom I saw in consultation with my friend Dr. J. 
Marion Sims, severe paroxysms were induced by each application of 
the " exhauster." In this case the operator placed the whole body, 
with the exception of the head, in a vacuum. In another instance, 
exhaustion from the leg alone caused syncope every time the operation 
was performed. 

Pressure upon or obliteration of the arteries supplying the brain is 
another cause, and may be produced by ligation of the arteries or by 
tumors of various kinds. Feebleness of the heart's action, such as 
results from fatty degeneration, may also occasion cerebral anaemia. 

As we have seen, excessive mental exertion is a common cause of 
cerebral congestion. Strange as it may appear, I have had several 
cases of cerebral anaemia under my care, in which the disease was 



74 DISEASES OF THE BRAIN. 

clearly the result of a like cause, and these were instances in which 
the brain had been overtasked to an extreme degree. A little reflec- 
tion will, I think, show that such cases are strictly in accordance with 
what takes place in other parts of the body. Thus, we see the moder- 
ate use of a muscle or set of muscles increase their size and strength. 
Inordinate exercise induces hypertrophy, but, if the power of the 
muscles be still more severely tried, atrophy results. One of the worst 
cases of progressive muscular atrophy I ever saw occurred in the per- 
son of a ballet-dancer, whose gastrocnemii muscles were the apparent 
starting-points of the disease. Excessive cerebral action produces 
exhaustion, and exhaustion causes anaemia, as surely as anaemia causes 
exhaustion. 

The action of mental emotions is more obvious. We know that 
some emotions increase the amount of blood in the brain. Others di- 
minish it, and sometimes with such suddenness as to cause syncope. 
Fear is one of these, and we have all seen the face become paler under 
its influence. 

Certain medicines are causes of cerebral anaemia, both by their 
action on the vaso-motor nerves and in diminishing the power of the 
heart. Tobacco, tartarized antimony, calomel, oxide of zinc, and the 
bromides of potassium, sodium, calcium, and lithium, are among the 
chief of these. I was the first to point out this influence of the bro- 
mides, and, in a recently-published memoir, 1 have given several cases 
in illustration of its action. The drowsiness, vertigo, nausea, faint- 
ing, weakness of the muscular system, numbness, failure of memory, 
mental aberration, pallor of the countenance, and anaemia of the reti- 
na, all go to show that the quantity of blood in the brain is dimin- 
ished. Recent investigations not yet published have convinced me 
that the oxide of zinc acts in a similar manner. 

Insufficient nutrition, either from deficient or improper food or dis- 
ease of the digestive or assimilative organs, is a very common cause. 
Through its influence not only is the absolute amount of blood less- 
ened, but its quality is deteriorated. The quantity sent to the brain 
is hence diminished, and that which is supplied is lacking in its proper 
proportion of red corpuscles. Many of the cases of cerebral anaemia 
occurring in large cities originate from such influences, and likewise 
from the vitiated air of narrow and crowded streets, from cold, and 
from deprivation of light. 

Sudden cerebral anaemia may be produced by the shock caused by 
physical injuries, or even slight surgical operations unattended by 

1 " On Some of the Effects of the Bromide of Potassium when administered in Large 
Doses." Quarterly Journal of Psychological Medicine, January, 1869, p 46. In this 
paper I stated that one of the most constant phenomena was contraction of the pupils. 
Very greatly increased experience has convinced me that this is an occasional circum- 
stance, which occurs during the early period of administration only. 



CEREBRAL ANAEMIA. 75 

effusion of blood. Thus I have several times seen it follow immedi- 
ately on the passage of a urethral catheter or bougie for the first time. 

The passage of a galvanic current of too great a degree of intensity 
through the brain may be productive of alarming symptoms due to sud- 
denly-induced cerebral anaemia. Upon one occasion I passed a current 
from ten cells transversely through the brain of a gentleman — the poles 
being on the mastoid processes — with the effect of causing syncope, 
extreme nausea, a cold perspiration on the head and face, and such 
feeble action of the heart as to cause me to apprehend the most serious 
results. Placing the head in the dependent position, and causing him 
to inhale the nitrite of amyl, soon restored him to consciousness, and 
dissipated the other symptoms. 

In another, somewhat similar though not so violent symptoms were 
induced by the passage of a current from only six cells. Cologne to 
the nostrils, and a draught of strong whiskey, afforded prompt relief. 

These cases, as well as others within my knowledge or experience, 
show how sensitive some persons are to the primary current, and indi- 
cate the care necessary in the use of this powerful agent. 

An instance of extreme cerebral anaemia, produced by excitation of 
the pneumograstic nerve by a galvanic current of too great a degree of 
intensity, will presently be cited. 

Diagnosis. — The principal affection with which cerebral anaemia is 
liable to be confounded, is cerebral congestion. Indeed, there is no 
other which can be mistaken for it, if even ordinary perception and 
judgment be exercised. 

From this it may be diagnosticated by the history of the case, and 
a careful inquiry into the etiology, by the facts that drowsiness, not 
wakefulness, is a prominent symptom ; that the pupils are dilated in- 
stead of being contracted ; that the pain is more apt to be fixed in a 
limited part of the head instead of being general ; that it and the ver- 
tigo are increased by the assumption of the erect position, and dimin- 
ished by lying down ; that the ophthalmoscope shows retinal anaemia ; 
that the face is pale and the skin cold ; that the pulse is weak and fre- 
quent ; and that bellows-murmurs are heard at the base, of the heart 
and in the veins of the neck. The effect of stimulants and tonics in 
mitigating these symptoms, and the fact that they are increased by ex- 
ertion and debilitating influences, are also important points to be con- 
sidered in forming a diagnosis. Attentive consideration of these dif- 
ferential phenomena will prevent a mistake which may be fatal to the 
patient. 

Prognosis. — The prospect of recovery in cases of cerebral anaemia 
depends mainly upon the removal of the cause, and the adoption of 
suitable treatment. In those cases which are the result of sudden and 
profuse loss of blood, the prognosis is grave, and this is especially so if 
the patient is pulseless and convulsions have occurred. In such in- 



76 DISEASES OF THE BRAIN. 

stances, even though the haemorrhage has been arrested, it may be 
impossible to save the patient. 

In the gradually-developed form the prognosis is generally favorable. 

Morbid Anatomy. — The vessels of the brain and its membranes are 
observed upon post-mortem examination to contain less than the normal 
amount of blood. The tissue of the brain is pale, and section shows a 
diminished number of the red points in the white substance. Some- 
times there is an increased amount of serous effusion in the sub- 
arachnoid space, but the ventricles are generally empty. 

Pathology. — The questions to be discussed under this head are 
similar to those connected with the same point in cerebral congestion. 
That the quantity of blood within the cranium can be diminished as 
well as increased admits of no doubt, and the fact that the symptoms 
grouped together as indicating the existence of cerebral anaemia are 
really the result of deficient blood-supply to the brain is equally certain. 
The experiments of Kussmaul and Tenner, 1 as well as those of other 
physiologists, are perfectly convincing. 

To observe in man the effects of even temporarily cutting off the 
supply of blood to the brain, it is only necessary to compress the 
carotid arteries for a few moments. I have repeatedly done this in rab- 
bits to the extent of producing insensibility and convulsions. Jacobi 2 
relates the following symptoms as generally observed in the human 
subject : Dimness of sight, dizziness, stupor, weakness in the legs, stag- 
gering, swooning, loss of consciousness, and sudden apoplectic falling 
down. 

Dr. Alexander Fleming 3 tried the effect of compressing the carotid 
arteries. " There is felt a sort of humming in the ears, a sense of tingling 
steals over the body, and in a few seconds complete unconsciousness 
and insensibility supervene, and continue as long as the pressure is 
maintained. I have recently performed this experiment several times, 
with the effect of producing similar phenomena, together with pallor 
of the countenance, dilatation of the pupils, and temporary headache." 

In many cases of cerebral anaemia, the cause, as we have seen, 
resides in the blood-producing functions, and is such as to cause the 
formation of blood which does not contain its due supply of red cor- 
puscles. Here, although there may be no diminution in the actual 
volume of this fluid circulating in the cerebral vessels, the effect is the 
same so far as the nutrition of the organ is concerned, and hence the 
symptoms of anaemia are slowly evolved. 

1 " Untersuchungen uber TTrsprung und Wesen der fallsuchtartigen Zuckungen." 
Frankfurt, 1857. Also, "On the Nature and Origin of Epileptiform Convulsions, caused 
by Profuse Bleeding," etc. New Sydenham Society Translation, 1859. 

2 Quoted by Kussmaul and Tenner. 

3 British and Foreign Medico- Chirurgical Review, April, 1855, p. 529, in a paper en- 
titled " Note on the Induction of Sleep and Anaesthesia by Compression of the Carotids." 



CEREBRAL ANAEMIA. 77 

Again, it cannot be doubted that spasm of the blood-vessels pro- 
duced through the sympathetic and vaso-motor nerves explains the 
origin and continuance of many cases of cerebral anaemia. It is in this 
way that mental emotions act, and sometimes with such rapidity as to 
cause instant death. This spasm may be kept up for a very consid- 
erable period, with the effect of developing the ordinary symptoms of 
cerebral anaemia, even after the emotion which originated it has long 
since disappeared. 

Treatment. — The first indication to be fulfilled in the treatment of 
cerebral anaemia is to get rid of the cause. It often happens that this 
is still in active operation when patients come under our care, and 
there is no hope of permanent success till it is removed. Thus, if 
there is haemorrhage from a divided vessel, from the uterus, the bow- 
els, the lungs, or other part of the body, it must be arrested ; if there 
is exhausting discharge from the air-passages, the intestines, or the 
genital organs, it must be stopped ; if the digestive or assimilative 
organs do not perfectly perform their offices, they must be put in 
good condition ; if a tumor or other obstruction to the due course of 
the blood to the brain exist, it must be removed ; and if the hygienic 
conditions surrounding the patient be bad, or the food inadequate in 
quantity or quality, they must be improved. 

No medicine exercises so powerful an effect in cerebral anaemia as 
alcohol in some form or other. Perhaps, all things considered, the 
spirituous liquors, such as whiskey, brandy, and rum, are more gen- 
erally applicable ; for the influence is more rapidly felt, and there is 
not the same risk of exciting or aggravating gastric disorder as when 
vinous or malt liquors are used. The quantity must be regulated ac- 
cording to the circumstances of each case, and should always be large 
enough to materially increase the force of the heart. 

But if this were the only effect of alcohol, its benefits in cerebral 
anaemia would be but temporary, and would certainly be followed by 
a period of depression. Aside, however, from its stimulating action 
on the heart, its tendency is to improve the appetite and digestive 
power, and to relax any spasm of the blood-vessels that may be 
present. 

Occasionally it happens that alcohol is badly borne by anaemic pa- 
tients. The brain has for so long a time been deprived of a due 
amount of its natural stimulus — blood — that time is required to enable 
it to tolerate, and be improved in tone by, the increased supply. Thus 
the physician will find that in some cases the patients will be appar- 
ently rendered worse by the remedy which of all others is calculated 
to do them most good. The headache and vertigo are increased, the 
general feeling of debility and malaise greatly augmented, and the 
complaint is made that the liquor has " gone to the head." 

Now, it must be recollected that the brains of anaemic persons are 



78 DISEASES OF THE BRAIN. 

in very much the same condition as the eyes of those who have for a 
long time been shut out from their natural stimulus — light. When 
the full blaze of day is allowed to fall upon their retinae, pain is pro- 
duced, the pupils are contracted, and the lids close involuntarily. The 
light must be admitted in a diffused form, and gradually, till the eye 
becomes accustomed to the excitation. So it is with the use of alcohol 
in some cases of cerebral anaemia. The quantity must be small at 
first, and it must be administered in a highly-diluted form, though it 
may be frequently repeated. Cases in which this intolerance of stimu- 
lants is exhibited are almost invariably of long duration, and are as 
those in which from a like cause wakefulness is produced by the re- 
cumbent posture. 

The carbonate of ammonia, or the aromatic spirits of ammonia, 
may be given if there are any special reasons why alcohol should not 
be used, but they are not to be compared to it in efficacy. 

In very extreme cases ether is preferable for the time being to any 
of the foregoing remedies, on account of its diffusive nature ; and 
transfusion may be necessary to save life. 

My recent experience disposes me to put a very high value upon 
the nitrite of amyl in the treatment of cerebral anaemia. Aldridge ' 
has shown that it causes, when inhaled, dilatation of the retinal arte- 
ries ; and the other phenomena of its action, the feeling of fullness in 
the head and the redness of the face and scalp, unite to prove that it 
exercises a like effect over the vessels of the brain. 

In the cerebral anaemia of weak and chlorotic girls it is especially 
valuable, although there is no form of the affection, whether transitory 
or permanent, in which it will not prove beneficial. Even a single 
dose of four drops inhaled from a handkerchief has repeatedly in my 
hands relieved anaemic headaches, and effectually dissipated syncope, 
the result of a feeble action of the heart. Upon one occasion I had, 
rather imprudently, perhaps, acted in a case of goitrous exophthalmia 
upon the pneumogastric nerve with a galvanic current of too great a 
degree of intensity. The heart was rendered exceedingly weak and 
irregular in its pulsations. The patient, a lady, became insensible 
from syncope, and was unable to swallow the brandy I held to her 
lips. I poured a few drops of the nitrite of amyl on a handkerchief 
and held it to her mouth. Immediately the action of the heart be- 
came stronger, the color began to return to the face, and conscious- 
ness was at once regained. 

In chronic cerebral anaemia, the nitrite of amyl should be admin- 
istered in doses, by inhalation, of from four to eight drops three times 
a day. This course may be continued as long as may be necessary, 
without the slightest deleterious result. I have repeatedly persevered 
with it for a year, in cases of epilepsy, with the happiest effect. It 
1 "West Riding Lunatic Asylum Reports," vol. i., 1871, p. 77. 



CEREBRAL ANAEMIA. 79 

has never in my experience been requisite to use it longer than a few 
weeks in cases of cerebral anaemia. 

Among the more efficacious medicines to be employed in cerebral 
anaemia, opium and its preparations occupy a high place. Several 
years since I pointed out 1 the effects of opium upon the cerebral circu- 
lation, and, as the result of many experiments, urged that this drug 
should be used in brain-diseases with due discrimination. It was then 
shown that small doses of opium increase the supply of arterial blood 
to the brain. In the treatment of cerebral anaemia I have derived the 
most decided benefit from doses of opium not exceeding half a grain, 
and preferably a quarter of a grain, given three or four times a day, 
and continued for several weeks. An equivalent or even smaller pro- 
portional dose of morphia may be exhibited, instead of the entire drug. 

It may seem strange, with the cases I have given, and with the 
knowledge, from experiment and ophthalmoscopic examination, rela- 
tive to the power of the primary galvanic current applied to the brain 
or sympathetic nerve to contract the cerebral blood-vessels, that I 
should recommend the use of galvanism in cases of cerebral anaemia. 
Clinical experience, however, shows that it is decidedly beneficial, pro- 
vided the tension be very low. I am satisfied that not more than two 
or three cells should be brought into action in such cases, and that the 
current should only be passed for a few seconds at a time. 

As adjuncts to these means, the bitter tonics, such as quinine, 
gentian, columbo, and quassia, are useful. Iron is almost always re- 
quired, though there are patients who do not tolerate it. In such cases 
manganese may be substituted with advantage. I have frequently used 
the sulphate, in doses of five grains, with excellent results. When iron 
is borne, I know of no better combination than that given on page 68. 
Cod-liver oil is also a valuable agent in the disease under consideration. 

It must not be forgotten that food is the most important factor in 
relieving chronic cerebral anaemia. The main permanent influence of 
stimulants and tonics is exerted upon the appetite and digestion, and 
the blood and tissue forming functions, mainly as an excitant. The 
real strength must come from the food. This should, therefore, be of 
good quality ; animal food, such as milk, eggs, and meats of various 
kinds, forming its chief portion. 

The influence of position should always be taken advantage of to 
facilitate the flow of blood to the head, and the erect posture avoided 
as far as possible, especially during the early stages of the treatment. 
Thus the patient should be encouraged to pass a good portion of the 
day in a recumbent position, and should be instructed to assume it ai 
once on the occurrence of any aggravation of the symptoms. 

The opposite course is fraught with danger. Physicians are often 
anxious that their patients should take physical exercise, but it must be 
J " Sleep and its Derangements." Philadelphia, 1869, p. 25. 



80 DISEASES OF THE BRAIN. 

remembered that those who suffer from cerebral anaomia have very little 
vital energy, and a diminished amount of blood is circulating through 
the organ from which the greater part of their nervous power comes. 
Muscular exercise lessens the energy, and still further reduces the 
quantity of blood in the brain, for the muscles require an increased 
supply while in a state of activity. To be sure, after the strength of 
the system is in a measure improved, the blood increased in quantity 
and quality, and the brain supplied with something like its proper pro- 
portion, moderate physical exercise is of the greatest service. 

I have several times witnessed severe consequences from the as- 
sumption of the sitting or erect position too soon after a profuse 
haemorrhage, and in one case death resulted. 

As regards mental labor, there is not much need of caution, for the 
reason that it is impossible for the patient to undertake it to any dan- 
gerous extent. But, as he improves in strength, the desire to make use 
of his increased power may be manifested. It is, therefore, well at this 
time to prohibit any such exertion as will probably be followed by 
marked depression. Moderate mental exercise is, however, far from be- 
ing prejudicial, for it tends to increase the amount of blood in the brain. 

Emotional disturbance should also, as a rule, be avoided, although 
at times it may be productive of great benefit, especially if it be pos- 
sible to bring into action an emotion contrary to that which may have 
produced the disease. Thus a lady became subject to cerebral anosmia, 
directly the result of painful emotions due to domestic trouble. The 
cause was very suddenly removed, or rather the knowledge of its re- 
moval was suddenly communicated to her. The reaction was very great ; 
she was thrown into a state of joyous excitement, attended with consid- 
erable febrile disturbance, and I was apprehensive for a time that her 
mind might become permanently deranged, for there were hallucinations 
and delusions of various kinds, and many symptoms of cerebral conges- 
tion. But in the course of a few days, during which she was kept in entire 
seclusion, and as far as possible from all mental and physical agitation, 
she entirely recovered both from the secondary and primary disorders. 



CHAPTER III. 

CEREBRAL HEMORRHAGE. 



Under the designation of cerebral haemorrhage I propose to con- 
sider that disease which is often known as apoplexy, hemiplegia, or a 
paralytic stroke, and which is due to the rupture of a blood-vessel, and 
the consequent extravasation of blood either into the substance of the 
brain or into its ventricles. 



CEREBRAL HEMORRHAGE. 81 

Two forms of the affection, differing essentially only in the extent 
or seat of the lesion, but presenting different symptoms, are to be dis- 
tinguished ; these are the apoplectic and paralytic. In the first there 
is loss of consciousness ; in the second the mind, though perhaps im- 
paired, is not suspended in its action. 

Symptoms. — Before the full development of the attack there often 
is, for several days, a group of symptoms present which indicate cere- 
bral disorder. These are very much of the same character as those 
denoting the first stage of cerebral congestion, but, though generally 
not so numerous, are far more striking. 

Among the more obvious is a sudden difficulty of speech, arising 
from slight paralysis of the tongue and other muscles concerned in 
articulation. Words are not pronounced with the usual distinctness ; 
the tongue seems to occupy more space in the mouth than it should, 
and is not moved with the requisite degree of promptness and rapidity. 

The other muscles on one side of the face may be affected, and 
hence there is a little distortion, lasting, perhaps, but for a few hours. 

Defects of sight may occur, usually characterized by the presence of 
dark spots in the axis of vision. Such conditions are due to minute 
extravasations in the retinse, and are always of most serious importance. 
I have known retinal clots to precede by more than a year the occurrence 
of a more severe lesion. 

Bleeding from the nose is a common precursor, and, when occurring 
without being induced by severe muscular exertion, blows, a dependent 
position of the head s or other obvious cause in a person over the age of 
forty, is always to be regarded as a symptom of moment. 

Numbness limited to one side of the body is of itself sufficient to 
excite apprehension. I have known several cases in which this symptom 
was the only premonitory sign. It may be present several days before, 
or may precede the attack by only a few minutes. 

In addition, there may be headache, vertigo, slight confusion of 
mind, a tendency to stupor, and vomiting. 

None of the premonitory symptoms may be present, and then the 
attack, if of the apoplectic form, occurs with great suddenness. Even if 
they have been noticed, there is more or less of abruptness in the onset. 

Thus the individual is perhaps standing, engaged in conversation, 
when he is instantaneously struck with unconsciousness, and falls to the 
ground as if shot ; sensibility and the power of motion are abolished, 
and no signs of vitality are apparent to the ordinary observer, with the 
exception of the slow and labored action of the heart and respiratory 
muscles. The breathing is stertorous, the lips and cheeks are puffed 
out with each expiration, and the pupils are generally largely dilated 
and insensible to light. 

Reflex movements are abolished at first, but after a few moments 
they reappear, and are even more readily excited than in health, owing 
to the fact that the controlling influence of the brain is removed. 
7 



82 Diseases of the brain. 

The voluntary power of swallowing is lost, but it is usually not dif- 
ficult to cause contraction of the muscles of deglutition by excitation 
of the pharynx. When these cannot be produced, the prognosis is, if 
possible, increased in gravity, for the reason that the extravasation is 
probably in the medulla oblongata, or so situated as to compress it. 

The urine and faeces are often evacuated involuntarily. 

An apoplectic attack of this character usually terminates in death 
without the patient recovering his intellect in the slightest degree. If 
life should be prolonged for thirty-six hours, the probability of a fatal 
termination is materially lessened. I have never seen a case of cerebral 
haemorrhage that was instantaneously fatal, and, although from ana- 
tomical and physiological considerations I admit the possibility of such 
instances, I am persuaded that they must be rare. Jaccoud ' expresses 
the opinion that death is immediate in those cases in which the haem- 
orrhage is in the medulla oblongata, or in those which occur in both 
hemispheres. Dr. Hughlings Jackson, 2 on the contrary, though conced- 
ing from theoretical grounds that haemorrhage into or near the me- 
dulla oblongata might cause instant death, has never witnessed such a 
termination ; and Dr. Wilks 3 says that apoplexy is very rarely, if ever, 
a suddenly fatal disease, no matter what part of the brain may be the 
seat of the effusion. Among the reports of several thousand post- 
mortem examinations at Guy's Hospital, there was but one in which 
death was asserted to have been instantaneous, and that was a case of 
meningeal haemorrhage. Even this was doubtful, for the patient had 
fallen some distance from the hospital, and was brought in dead. 

I have several times had cases under my observation in which, it 
was said, death had been as sudden as though the individual had been 
struck by lightning ; but careful inquiry and post-mortem examination 
have either shown that the observers were deceived, or that there had 
been no extravasation at all, death being the result of heart-disease. 

Nevertheless there are instances on record in which haemorrhage 
into the medulla oblongata has produced death with as much sudden- 
ness as any other possible cause. Ollivier 4 cites a case which came 
under his observation at the Salpetriere: 

"Batandier (Jeanne Elisabeth), aged sixty-four, of medium height, 
and inclined to stoutness, was admitted to the Salpetriere, for attacks of 
hysteria, with which she had been affected since her seventeenth year, 
when her menses appeared. These attacks were very violent, and 
occurred at each menstrual period. They stopped during a single 
pregnancy at the age of thirty years, and disappeared altogether at 

1 " Traite de pathologie interne." Paris, 1870. Tome premier, p. 166. 
8 " On Apoplexy and Cerebral Haemorrhage." " Reynolds's System of Medicine." Lon- 
don, 1868. Vol. ii., p. 520. 

3 " Guy's Hospital Reports," 1866, p. 178. 

4 " Traite des maladies de la moelle epini&re." Troisi&me Edition, Paris, 1837, tome 
U M p. 140. 



CEREBRAL HAEMORRHAGE. 83 

forty, when her menses ceased. Her intelligence had not become 
seriously impaired; she had full power of speech, but complete deafness, 
existing since infancy, rendered this faculty almost useless to her, and 
she accordingly communicated with others by means of signs. She was 
very irascible, her gait was irregular, but nevertheless there was no 
paralysis. In all other respects her health was good. On the 28th of 
October, at mid-day, while in the midst of a group of women, she be- 
came very angry, uttered a cry, leaned against the wall, and then fell to 
the ground. She was raised up, but was dead. 

" Autopsy forty hours after death. . . . The sinuses of the dura 
mater were gorged with blood, the pia mater was strongly injected, 
and easily detached from the cerebral substance ; the middle lobe of the 
brain presented a well-marked depression ; the brain was firm, and of 
good consistence; the hemispheres, carefully examined, presented a de- 
cided injection of both the white and gray substance, but no heemor- 
rhagic foyer, old or recent ; the ventricles were empty, the choroid plex- 
uses thin and granular ; the optic thalami and corpora striata healthy. 

" After having divided the spinal cord below the medulla oblongata, 
and having removed the medulla oblongata with the cerebellum, and 
the pons Varolii, a sanguineous clot, irregularly round, and the size of a 
walnut, was discovered adherent to the posterior part of the medulla 
oblongata, and extending above as far as the opening into the fourth 
ventricle, which it entirely closed. The pyramids were not injured, but 
the olivary bodies were partly destroyed, the right more than the left. 
The restiform bodies were entirely detached, and were found in frag- 
ments in the middle of the clot. The clot was removed and the source 
of the haemorrhage was discovered to be in the central gray substance, 
four or five lines below the inferior border of the pons Varolii, which 
was a little softer than normal, but which in other respects appeared to 
be healthy, as did also the cerebellum. An enormous quantity of san- 
guinolent serous fluid filled the spinal canal, and flowed out in part from 
the foramen magnum, and in part from the opening made in the spine 
for the examination of the cord, which was healthy and non-injected. 

" Both lungs were gorged with black blood, but presented no traces 
of emphysema; the right cavities of the heart were filled with black 
blood, but the organ was healthy. 

" All the abdominal organs were in a normal condition." 

Ollivier remarks, in reference to this case, that death was as instan- 
taneous as though produced by a sudden luxation of the first or second 
vertebra. 

Dr. A. Charrier ■ has reported the case of a woman who, on the 

twelfth day after delivery, died instantaneously. At the evening visit, 

while talking, " she suddenly uttered a cry, turned over on her pillow, 

and was dead. Death was as instantaneous as though she had been 

1 " HSmorrhagie du bulbe racbidien." Archives de phynologie y 1869, p. 660. 



84 DISEASES OF THE BRAES. 

struck by lightning." At the autopsy a small clot was found in the 
centre of the medulla oblongata. The rest of the brain and the heart 
were perfectly healthy. 

In the majority of cases attended with complete loss of conscious- 
ness, the course of the disease is not so rapid or hopeless as in the form 
just described. The patient falls, is comatose, breathes stertorously, 
and presents a similar general appearance; but after a time conscious- 
ness begins to return, and it is possible to partially rouse him from the 
condition of insensibility. He turns over in the bed, though with diffi- 
culty, and may attempt to speak. Articulation is, however, indistinct, 
for the muscles of one side of the face are paralyzed, and the tongue, 
from a like cause, is restricted in its movements. The paralysis is found 
to exist in the limbs of the same side, and involves the loss of sensi- 
bility, as well as of motion, though rarely to the same extent. In some 
exceedingly rare cases, perhaps not clearly understood, the paralysis of 
the limbs is on the opposite side to that of the face. A man thus af- 
fected was present at my clinic, in October, 1870, at the Belle vue Hos- 
pital Medical College. He was a patient under my charge at the New 
York State Hospital for Diseases of the Nervous System, and had been 
attacked several years previously. His history, as elicited with great 
care by my clinical assistant and resident physician of the hospital, Dr. 
Cross, was perfectly clear on this point. 

The facial paralysis presents several points of great interest in a 
diagnostic point of view. The affected side is incapable of expression, 
but, so long as the patient does not attempt any facial movements, 
scarcely any distortion is perceived. Should he endeavor to open his 
mouth to spit, or to puff out his cheeks, the paralysis is at once noticed. 
Owing to the fact that the antagonism of the muscles is destroyed, the 
face is drawn toward the sound side, the angle of the mouth being 
slightly depressed. It is remarkable, however — and the fact is of im- 
portance as a diagnostic mark between the facial paralysis of cerebral 
haemorrhage with hemiplegia and the simple facial paralysis from injury 
or disease of the seventh pair— that the patient does not lose the ability 
to close the eye of the affected side. 

If the fifth pair of nerves is involved in the lesion, sensibility is im- 
paired, which is never the case in simple facial paralysis, and the -mas- 
seter and pterygoid muscles, which receive their motor influence from 
this nerve, will consequently be paralyzed. The ability to masticate on 
the affected side is therefore lost, and the cheek hangs lower than on 
the sound side. 

The tongue is also only paralyzed upon one side. When, therefore, 
it is protruded from the mouth, the point deviates toward the paralyzed 
side, owing to the uncompensated action of the sound genio-hyoglossus. 

All these paralyses occur on that side of the body opposite to the 
seat of the lesion. In a very few instances the paralysis has existed on 



CEREBRAL HEMORRHAGE. 85 

the same side with the lesion. This is explained by the fact that it oc« 
casionally happens, as Longet l states, that the decussation of the an- 
terior columns of the cord is imperfect. At times, again, owing to a 
double extravasation, or to the fact that the lesion is in the mesial hue 
of the pons, or that it forces its way so as to involve both hemispheres, 
both sides of the body are deprived of motion. 

Very inexact ideas have prevailed relative to the temperature in 
cases of cerebral haemorrhage. The researches of Bourneville 2 have 
given us more certain data than we previously possessed, and, aside 
from their value as contributions to symptomatology and pathology, are 
of great importance in the matter of prognosis. This observer, as the 
result of numerous determinations, arrived at the following conclusions: 

That the animal temperature, in the very inception of the apoplectic 
attack, undergoes a very considerable reduction, the thermometer in the 
rectum indicating 36° (=96.8° Fahr.), and even sometimes falling as 
low as 35.4° (=95.72° F.). This reduction seems to be influenced par- 
ticularly by the continuance of the haemorrhage and the supervention 
of additional centres of extravasation. To this period of temperature- 
depression succeeds another, during which the animal heat remains sta- 
tionary at its normal point. If the patient is destined to recover, this 
period is prolonged indefinitely ; but, if death is to ensue, a third period, 
characterized by a remarkable elevation of temperature, supervenes. 
During this stage the thermometer indicates 40° (= 104° Fahr.), or may 
rise to 41.5° (= 106.7° Fahr.). 

Charcot s has called attention to the fact that, in a few cases of cere- 
bral haemorrhage, an acute bed-sore forms on the buttock of the para- 
lyzed side. From the second to the fourth day after the occurrence of 
the attack, an erysipelatous redness of irregular outline occupies the 
buttock, and frequently extends over the greater part of its surface. 
Within forty-eight hours a dark-colored spot appears on the central 
portion, and the epidermis of this is raised by the sanguinolent fluid be- 
neath it. This vesicle breaks, and a sore is thus formed, which gradu- 
ally extends. Occasionally but very rarely the sore occurs on the sound 
buttock. I have only witnessed two cases in which these sores were 
formed, and both were in persons over seventy years of age. Of course, 
these eschars are not to be confounded with the bed-sores due to long- 
continued pressure. 

It is rarely the case that the third nerve is affected. When it is, 
there are external strabismus from paralysis of the internal rectus muscle, 
and ptosis from paralysis of the elevator of the upper eyelid. The 
pupil is dilated, and is insensible to light. 

1 " Anatomie et physiologie du systeme nerveux," tome L, p. 383. 

2 " Etudes cliniques et thermometriques sur les maladies du systeme nerveux." Paris, 
1872, p. 116. 

* " Sur la formation rapide d'une eschare a la fesse du cote paralyse dans l'hemipl6gie 
recente de cause cerebrale." Archives de physiologie, 1868, p. 308. 



86 DISEASES OF THE BRAIN. 

Another phenomenon is sometimes observed, and that is the rota- 
tion of both eyes toward the sound side. This is accompanied by 
a like movement in the head, so that, if the patient is paralyzed on 
the left side, the eyes and head are turned to the right, and conse- 
quently, as the patient lies in bed, the right side of his face rests on 
the pillow. I have observed these symptoms in about one-third of 
the cases of cerebral haemorrhage which have come under my observa- 
tion. They were present from the very beginning, and disappeared 
in a few days. 

Slight convulsive or involuntary movements are occasionally no- 
ticed. The most frequent of these is yawning, a .symptom which 
Dr. Todd 1 regards as troublesome, and even unfavorable, but which, 
in my experience, is not very annoying or dangerous. The other 
convulsive actions may be on the whole of either side of the body, or 
on both sides, or may be restricted to a single limb or even a group of 
muscles. 

Reflex movements are at first sometimes abolished, but subse- 
quently can generally be excited, especially in the lower extremity, 
by tickling the sole of the foot. Deglutition, though imperfect, can 
generally be made to take place by reflex action, unless, as pre- 
viously stated, the haemorrhage is in, or in the vicinity of, the medulla 
oblongata. 

The patellar tendon reflex will be found to be greatly exaggerated 
on the hemiplegic side, and slightly so on the sound side. This latter 
is owing to the fact that the motor decussation is seldom, if ever, com- 
plete, a small proportion of the motor fibres from the injured side of 
the brain passing into the same side of the spinal cord, where they are 
continued in what is known as the "uncrossed" or the "anterior" 
pyramidal tract. 

The ankle clonus can always be obtained on the paralyzed side if 
the rigidity and contractures of the leg-muscles are not too great. 
To produce this symptom, which is an alternating contraction and 
relaxation of the gastrocnemius, the weight of the leg should be sup- 
ported by one hand while the other hand grasp's the foot near the 
toes. Sudden and somewhat forcible flexion of the foot should then 
be made and maintained, when, if the conditions are favorable, the 
up-and-down movement of the foot will be obtained. 

Secondary contractures, the exaggeration of the patellar tendon 
reflex, and the ankle clonus, are all evidences of irritation of the 
spinal motor tract, and, following a cerebral haemorrhage, indicate a 
descending degeneration of the motor fibres. 

Strong tonic contractions of the muscles of the paralyzed limbs 
are occasionally a prominent phenomenon. The upper extremity is 
more apt to be their seat than the lower, and the biceps and triceps 
1 "Clinical Lectures." Second edition. London, 1861, p. 708. 



CEREBRAL HEMORRHAGE. * 87 

muscles are especially liable to be thus affected. This condition 
may exist at the very beginning of the seizure, or may subsequently 
supervene. 

Few systematic authors have noticed the symptom in question — a 
symptom which is not to be confounded with the secondary contrac- 
tions coming on several weeks after the attack, and. the origin of 
which is altogether different — attention seems to have been first called 
to it by Boudet, 1 but Durand-Fardel 2 studied it more thoroughly, 
and was the first to determine its connection with a definite lesion. 
According to this later author, primary contraction is only present 
in cases of cerebral haemorrhage when the extravasation reaches 
the ventricles or the subarachnoidal space. So long as the blood 
remains circumscribed in the cerebral tissue, there are no contrac- 
tions either in the paralyzed or the non-paralyzed limbs. Of twenty- 
six cases of cerebral haemorrhage, in which death ensued within one 
month, and in which the ventricles or the meninges had been invaded, 
there had been, in nineteen, contractions of the paralyzed members ; 
in three, contractions of the sound limbs ; and in four, resolution 
without contraction. 

Charcot, 3 in fourteen cases of ventricular or meningeal invasion, 
noticed contractions in eleven, and in two epileptiform convulsions. 
The contractions take place whether the membranes be distended by 
the clot, or whether rupture ensues. 

In the less severe apoplectic form of cerebral haemorrhage now 
under consideration, the urine and faeces are sometimes passed in- 
voluntarily from paralysis of the sphincters, and are at times obsti- 
nately retained from paralysis of the bladder and abdominal mus- 
cles. 

The mental symptoms are at first scarcely distinguishable from 
those which are present in the severest form of the disease. The 
coma and insensibility are complete, but after a time, which varies 
in duration with the extent of the lesion, consciousness begins to re- 
turn. The patient opens his eyes, and gives a little attention when 
loudly spoken to ; and is perhaps able to express, to some extent, 
his wishes by signs and gestures. Gradually the mental power in- 
creases ; he attempts to speak, but his words are misplaced or for- 
gotten, and his articulation, owing, as already stated, to the paralysis 
of the face and tongue, is thick and indistinct. Those words which 
are enunciated by the movements of the lips and tongue are especially 

1 " Memoire sur l'kemorrhagie des meninges." Journal des connaissances medico- 
chirurgicalcs, 1839. 

2 " De la contraction dans l'hemorrhagie cerebralc." Archives generates de medecine, 
1843, tome ii., p. 340. Also " Maladies des vieillards." Paris, 1873, p. 225. 

3 " Nouvelles recherches sur la pathogenie de Themorrhagie cerebrale." Archives 
de physiologic, 1868, p. 110. 



88 DISEASES OF THE BRAIN. 

troublesome, while those formed in the throat are not difficult to pro- 
nounce. 

The mental characteristics of the patient will be found to have 
undergone a radical change. He is irritable, unreasonable, and fret- 
ful. His sense of the proprieties of life, which may in health have 
been very delicate, becomes obtuse ; his memory is notably impaired, 
and his reasoning power greatly diminished. The greatest change, 
however, is perceived in the emotional faculties. He laughs at the 
veriest trifles, and sheds tears profusely at the least circumstances 
calculated to annoy him. Even for years afterward this peculiarity 
is noticed. 

Such is the first stage of an attack of cerebral haemorrhage marked 
by apoplexy and paralysis, as ordinarily observed when amendment 
takes place. It is often the case, however, that this stage is not 
fully developed, owing to the continuance of the haemorrhage. In 
such an event the coma becomes more profound, the breathing more 
irregular and less frequent, the pulse intermits and loses in force, 
the face becomes purple from imperfect aeration of the blood, and 
death ensues. In other cases a certain degree of improvement may 
be attained, and then the haemorrhage may recur, and the patient dies 
comatose. 

In a few cases which I have had under my charge, the first symp- 
tom observed has been intense pain in some part of the head. This 
has been quickly followed by nausea and the ejection of the contents 
of the stomach. There have also been slight wandering of the mind 
and a disposition to stagger in walking These phenomena have per- 
sisted for from four to six hours, and then the patients have gradu- 
ally passed into a comatose condition, with general resolution of the 
limbs. Death has ensued within twelve hours after the beginning of 
the symptoms. 

• In one of these cases, that of a gentleman of this city, he had re- 
marked to me, at six o'clock in the evening, that he was feeling 
remarkably well all day. For several years he had suffered from cere- 
bral hyperaemia, the result of continued and severe mental applica- 
tion. At about eight o'clock he was seized with the most agonizing 
pain in the head, attended with intense nausea. Repeated vomiting 
took place, and there had been slight delirium and momentary periods 
of forgetfulness. My friend Dr. Lente, of Cold Spring, who was in 
my house at the time, went with me to see him, in response to his mes- 
sage that I would call. We found him asabove described ; and, as he 
was firmly convinced that his stomach was at fault, an emetic of salt 
water was given him. It acted promptly, but without affording him 
the least relief. A hypodermic injection of a third of a grain of sul- 
phate of morphia was next administered, but without benefit ; and 
this was followed by a similar quantity after half an hour. He then 



CEREBRAL HEMORRHAGE. 89 

thought he might sleep a little, but the pain continued. An hour 
afterward I left him, being of the opinion, in which Dr. Lente shared, 
that he was either suffering from a cerebral tumor or an extravasation 
of blood. Two hours afterward I was again sent for. He was then 
comatose, the limbs in a state of resolution, the breathing of that loud, 
rauchous character, and the heart beating with the irregularity so in- 
dicative of effusion into, or in the neighborhood of, the medulla oblon- 
gata. Deglutition could not be excited by substances placed in the 
mouth. The right pupil was strongly dilated, while the left was a 
mere point. Death ensued within two hours afterward. 

The post-mortem examination was made the next day by Dr. S. 
D. Powell, in presence of Drs. Lente, Ripley, Elsberg, and myself. 
A clot the size of a small orange occupied the posterior part of the 
middle and central portion of the right lobes. It was entirely con- 
fined to the white substance. Another, about as large as a hickory- 
nut, was situated in the right half of the pons Varolii. 

In all probability the clot in the right hemisphere began to form 
first, and the second, into the pons Varolii, which was the immediate 
cause of death, did not originate till a considerably later period, indi- 
cated by the disturbances in the respiration and circulation, and the 
impossibility of exciting deglutition. 

In those cases in which the improvement has been progressive up 
to the point of partial resumption of the mental faculties, we find that 
a second stage characterized by different symptoms often supervenes. 
This is the period of inflammation. 

It may begin at a variable time after the occurrence of the extra- 
vasation, usually not later than the eighth day. It is marked by fe- 
brile excitement and pain in the head, the latter being often very 
severe. There is gastric derangement, as evidenced by nausea and 
vomiting ; and convulsive movements of the limbs, with contractions 
of the flexors of the paralyzed side, are generally present. Delirium 
is also a prominent feature. Sometimes there is obstinate wakeful- 
ness, and at others a strong tendency to coma. This stage may last 
three or four days, or at most five or six, when it either causes death 
by extension of the inflammation from the immediate vicinity of the 
lesion to other parts of the brain, terminates in the formation of an 
abscess, or gradually ends in resolution, with abatement of the symp- 
toms. 

Disregarding for the present the first two of these results, we pro- 
ceed with the consideration of the phenomena of a case in which reso- 
lution takes place. 

With the cessation of the inflammatory action, the improvement 
of the patient becomes very marked. His speech is every day more 
distinct, his mind more active, his paralyzed limbs more capable of 
motion. Usually the leg recovers power with much greater rapidity 



90 DISEASES OF THE BRAIN. 

than the arm, and thus the patient is able to walk tolerably well 
before he can raise his arm from his side, bend the elbow, or 
extend the fingers. The paralysis in the leg is most marked in 
those muscles whose office it is to elevate the foot, and this neces- 
sitates a peculiar gait in order to avoid dragging the toes along 
the ground. The abductors are rarely affected to any great ex- 
tent. The patient in walking, therefore, throws the leg out from 
the body, and then, swinging it around, clears the ground in this 
manner. 

In the upper extremity there is almost invariably a disposition 
toward contraction of the pectoralis major and minor muscles, by 
which the arm is drawn across the front of the thorax. At the same 
time the latissimus dorsi, the trapezius, the rhomboidei, the teres 
major and minor, are generally in a state of relaxation, and eventu- 
ally tend to atrophy. The elbow is slightly flexed, the wrist bent 
upon the forearm, and the fingers drawn in toward the palm of the 
hand. These actions may, in a great measure, be prevented by appro- 
priate treatment, and they may vary in extent according to the gravity 
of the attack. It is a curious fact that the muscles of respiration 
are never paralyzed in cerebral haemorrhage unless the medulla oblon- 
gata be involved. 

Trousseau 1 has insisted with great force on the fact that, when 
the arm regains power before the leg, the termination is always fatal. 
There is no foundation for this theory. Whether the arm or leg re- 
covers first, depends upon the extent and situation of the haemor- 
rhage. 

Now, with all these troubles of motility, sensibility may likewise 
be involved to a greater or less extent. When this is the case, the 
limbs of the affected side at first feel heavy as if made of lead, and 
after a while numbness, as exhibited by a feeling as if ants were 
crawling over the skin, or water trickling over it, as if pins and 
needles were sticking in it, or as if that part of the body were 
"asleep," is noticed. Sometimes the sense of touch is greatly less- 
ened, while the ability to feel pain is scarcely impaired, and indeed 
is often considerably increased. Again, there may be hyperaesthesia 
of the skin of the affected regions, and pain along the course of the 
nerves. 

The circulation is inactive in the paralyzed limbs, and this, to- 
gether with the deficient nervous power, tends to cause a permanent 
reduction of temperature. The difference may amount to as much 
as five or six degrees, and, as the ability to resist cold is diminished, 
the patient is obliged to use additional covering on the paralyzed 
members. 

lu Lectures on Clinical Medicine." Bazire's Translation. Part I. London, 1866, 
p. 16. 



CEREBRAL HAEMORRHAGE. 91 

From continued disuse, atrophy of the paralyzed muscles always 
takes place unless suitable treatment be begun at an early period. 

Thus far we have only considered those attacks of cerebral haem- 
orrhage which are accompanied with unconsciousness. One of these 
forms kills, without the patient so far recovering as to show whether 
he is paralyzed or not, though of course he is so to a profound degree ; 
the other allows of more delay ; the brain can still act to some extent, 
and, if death does not ensue from continuance of the haemorrhage, 
the patient is found to be paralyzed on the side of the body opposite 
to the seat of the brain-lesion. One other form requires notice, and 
it is, perhaps, the one most frequently met with. It differs from the 
attacks just described in the important fact that it is unattended with 
unconsciousness. 

Like the others, this species of cerebral haemorrhage may take 
place very suddenly, without premonitory symptoms, or it may, like 
them, happen while the patient is said to be asleep. Generally, how- 
ever, though there may be no long prodromatic stage, there are symp- 
toms occurring immediately before the attack which indicate both 
mental and physical disturbance. These are headache, vertigo, numb- 
ness, vomiting, irritability of temper, and, perhaps, slight difficulties 
of speech. 

When the attack comes, the individual, if standing, falls, from the 
immediate paralysis of one leg. He is fully sensible of his condi- 
tion, although there is generally more or less mental change. The 
arm and face are affected, and the speech is rendered impossible or 
indistinct. 

If the patient be sitting or lying, he is aware that something has 
happened, but does not discover its exact character till he attempts to 
rise. A distinguished general officer of the army, after a fatiguing 
day of ceremony, entered his carriage with his wife, to be driven to 
his hotel. As he passed along Fifth Avenue he felt an indescribable 
sensation, and immediately afterward noticed that he could only see 
the half of objects. He made no effort to speak, though he is con- 
fident he did not for a moment lose his consciousness. When he 
attempted to get out of the carriage he found, to his surprise, that 
he was paralyzed on the right side, and that his speech was so much 
impaired that he could not be understood. 

Another gentleman was reading an amusing book, at which he 
laughed heartily. He felt suddenly a feeling of vertigo, and the book 
dropped from his hand. He attempted to pick it up, but found he 
had lost power in the arm, and, on trying to call to his wife, who was 
in the same room) discovered that he could not speak. At this time 
he could walk, but in a moment or two afterward he fell, from paral- 
ysis of his leg. So far as the paralysis is concerned, I have rarely 
seen a more severe case than this. 



92 DISEASES OF THE BRAIN. 

Another went to bed, perfectly well to all appearance, having en- 
joyed uninterrupted good health for several years. In the morning 
he arose, but felt a little pain in his head. As he stood before his 
glass, he thought his face was slightly twisted, and he noticed as he 
was shaving himself that he did not feel the razor on one side. While 
he was testing his facial mobility and sensibility, he experienced a 
trace of numbness in his left hand. This gradually increased, and in 
addition the limb lost power. In a few minutes he could not move it 
at all. By the time I saw him — two hours afterward — the paralysis 
had extended to the leg. At no period was there insensibility or 
mental confusion. 

A gentleman retired at night in good health. On attempting to 
get out of bed he discovered that he was paralyzed in the leg. Nei- 
ther the arm nor the face was affected. 

In the case of a gentleman of this city whom I saw in consultation 
with Dr. W. M. Polk, and who had for several years suffered from 
frequent severe headaches and other cerebral symptoms, the only phe- 
nomenon was binocular hemianopsia, with occasional slight delirium. 
Dr. H. Knapp, who saw the patient before I did, discovered no altera- 
tions in the functions or structure of the eye, and we all agreed that 
the case was one of very slight cerebral haemorrhage. 

Several cases have been under my care in which only the face or 
the tongue was paralyzed ; others in which the arm alone was in- 
volved ; and others, like the one just mentioned, in which the symp- 
toms were confined entirely to the leg. Sometimes there was a mo- 
mentary feeling of vertigo, sometimes a vacant stare, something like 
that of the petit mal of epilepsy, sometimes a slight degree of intel- 
lectual confusion, sometimes headache, and, again, no head-symp- 
toms whatever. The subsequent progress of such attacks requires 
no special consideration beyond that already given to the more severe 
forms. 

Now, no matter how light the attack may have been, nor how 
rapid the improvement, the patient who has had cerebral haemorrhage 
is never mentally or physically the same as he' was before. If the 
seizure has not been severe, he may advance so far toward a complete 
cure as to evince very little disorder of his mind or body. But close 
observation shows that he is not entirely restored, and, though he may 
do very well for light intellectual and physical exertion, severe labor 
of either kind is beyond his powers — and no one is more sensible of 
this fact than himself. Even after years his emotions are abnor- 
mally excitable. A patient in the New York State Hospital for Dis- 
eases of the Nervous System informed me that he shed tears every 
time a funeral passed him, and that even hearing of any one's death, 
or reading the obituary column in a newspaper, caused his feelings 
to get the better of him. In the lightest forms of the attack, this 



CEREBRAL HEMORRHAGE. 93 

easily-aroused emotional disturbance is a marked feature for years 
subsequently, if it ever entirely disappears. And as regards the mus- 
cles which have been paralyzed, it is very certain that, though they 
may be made strong enough for all practical purposes, they never can 
be restored to their former sound condition. 

The character and general mental type of the individual usually 
undergo some change ; and this may be to the extent of reversing his 
ordinary traits. 

Causes. — Advanced age is one of the most influential circumstances 
which predispose to an attack of cerebral haemorrhage, and this fact 
has long been known. Thus Hippocrates 1 states that apoplexy is 
most common between the ages of forty and sixty, and modern inves- 
tigation establishes the truth of the proposition as regards the actual 
number of cases. It is probable, however, that the liability increases, 
as Dr. Flint 2 says, from the age of twenty upward, and that there are 
not so many cases occurring in persons over sixty as below, for the 
reason that the number of individuals alive of that age is less. 

Of three hundred and eighty-three cases of cerebral haemorrhage 
which have been under my professional care, at some time or other 
after the occurrence of the extravasation, in my private and hospital 
practice, and in which the age of the patient is noted, three hundred 
and forty-one occurred in persons over forty years of age. Of these, 
three hundred and eleven were between forty and sixty, thirty-three 
between sixty and seventy, five between seventy and eighty, and three 
over eighty. 

Of the thirty-one cases in persons under forty, twenty were be- 
tween forty and thirty, ten between thirty and twenty, and one un- 
der twenty. This latter was a boy of seventeen, whom I exhibited 
at my clinic at the Bellevue Hospital Medical College in the autumn 
of 1870. 

The disease is certainly more common among men than women, 
though some authors have asserted the contrary. Falret ascertained 
that, of twenty-two hundred and ninety-seven cases, sixteen hundred 
and sixty occurred in males and only six hundred and thirty-seven in 
females. In my own experience, of three hundred and eighty-three 
cases, two hundred and fifty-nine were in males and one hundred and 
twenty-four in females. 

Temperament and organization are supposed to have an influence 
in predisposing to cerebral haemorrhage. It was formerly thought 
that those of sanguine temperament and plethoric habit who had stout 
bodies, large heads, florid complexions, and short, thick necks, were 
especially liable ; but more exact and thorough investigation would 

1 " Aphorisms," chapter vi., aphorism 57. 

2 " A Treatise on the Principles and Practice of Medicine." Third edition, Philadel- 
phia, 1868, p. 582. 



94 DISEASES OF THE BRAIN. 

appear to show that such is not the case, and that thin and pale indi- 
viduals show fully as great a proclivity. Dr. Flint 1 expresses the 
opinion that there is no special apoplectic constitution, and my own 
experience is decidedly to the same effect. 

That the tendency to cerebral haemorrhage is often hereditary 
appears to be very certainly established. Within my own knowledge, 
I am aware of several striking instances which support this opinion. 
A gentleman consulted me for hemiplegia, the result of cerebral 
haemorrhage, whose grandfather, father, two uncles, two brothers, 
and one sister had died of this disease, and whose son, thirty-six 
years of age, had been attacked. In another case a lady had her 
father, two brothers, and one sister die of the disease ; and, in a third 
very remarkable case, the great-grandfather, grandmother, father, four 
uncles and aunts, and two brothers, all in a direct line, died of cere- 
bral haemorrhage. 

Piorry 2 cites the case of a woman, herself paralytic, whose three 
children had died of convulsions, and whose mother, uncle, and broth- 
ers and sisters, to the number of twelve, had died of cerebral haemor- 
rhage or convulsions. It has very often happened in my experience that 
the father or mother of a hemiplegic patient, whose condition resulted 
from cerebral haemorrhage, had been affected in a similar manner. 

As regards the influence of diseases of the heart, Legallois, Briche- 
teau, Rostan, Andral, and Bouillaud 3 adduce instances in support of 
the existence of. a definite relation. While others, among whom Ro- 
choux, Walshe, and Flint are to be placed, deny the existence of any 
such causative influence. As tending to produce active or passive 
cerebral congestion, disease of the left or right side of the heart would 
reasonably seem to be conducive to the occurrence of cerebral hsemor- 
rhage. The tension of the blood in the vessels of the brain is in- 
creased thereby, and the liability to the rupture of a diseased vessel 
rendered greater. 

The condition of life has also been supposed to exert an effect in pre- 
disposing to cerebral haemorrhage, it being asserted by some authors 
that the affection is much more common with the rich, and those living 
in ease, luxury, and refinement, than in the poor and laboring classes. 

It is difficult to arrive at any very definite conclusion on this point, 
owing to very obvious reasons, but I am inclined to think the theory 
to be not well founded. It is only necessary to visit our large hos- 
pitals, to see how many of the inmates, drawn as they generally are 
from the laboring classes, are suffering from cerebral haemorrhage or 
its effects. 

Thus far we have only considered the more important, intrinsic, 

1 Op. cit,, p. 583. 

2 "Dc l'heredite dans les maladies," p. 107. 

3 " Traite de clinique des maladies du coeur," second edition, tome ii., p. 580. 



CEREBRAL HEMORRHAGE. 95 

predisposing causes ; there are, however, others which may be called 
extrinsic. 

Season is one of the chief of these. The disease is much more 
common in winter than in the other seasons, although some statistics 
would seem to show more cases during summer. A careful examination 
of such, however, shows that under the head of apoplexy is included 
not only cerebral, hasmorrhage, but congestion, sunstroke, embolus, and 
in fact nearly every other affection attended with sudden loss of con- 
sciousness. My own researches have been very exact on this point, and 
as their results I find that, of the three hundred and eighty-three cases 
of which I have notes, one hundred and forty cases occurred in winter, 
eighty-one in spring, ninety-seven in summer, and fifty-eight in autumn. 
It has been noticed, too, that sudden variations of temperature, especially 
from mild to cold weather, increase the number of cases of cerebral 
hasmorrhage. 

Of the exciting causes, a long list can readily be made. Among 
them are the excessive use of alcoholic liquors and other stimulating 
substances; the use of opium in excess ; the ingestion of large quantities 
of food, especially such as is stimulating and indigestible ; excessive 
physical or mental exertion, strong emotional disturbance, such as anx- 
iety, extreme joy, anger, or terror ; the act of coition, especially in old 
people ; straining at stool ; enlarged prostate, or paralysis of the 
bladder, requiring strong muscular efforts for the evacuation of the 
urine ; childbirth ; tight clothing about the neck, chest, or abdomen ; 
certain occupations which require the head to be depressed ; vomiting, 
sneezing, coughing, and laughing ; exposure to the direct rays of the 
sun or other sources of great heat ; the sudden arrest of a custom- 
ary flux, such as hasmorrhoidal bleeding ; the sudden application of 
cold water to the body ; long-continued bathing in very warm water ; 
the circumstance that the patient has had a previous attack, and certain 
diseases, as gout and syphilis. 

In regard to some of these causes, I may state that several very in* 
teresting cases have occurred in my own practice. In one, a lady was 
attacked on hearing that her cook had left her; in another the emotion 
excited by the fall of a picture from the wall caused a seizure. Four 
cases produced by straining at stool have come under my observation. 
In one of them a gentleman well known in public life retained sufficient 
consciousness and intelligence to take a large key out of his pocket with 
the non-paralyzed hand, and to rap on the floor for assistance. 

Two cases occurred during sexual intercourse, one in a man, the 
other in a woman. In one of these there was, subsequently, a great 
increase of venereal desire. In one case, the seizure was induced by 
stooping over to tie the shoe. This was in the boy, seventeen years of 
age, already mentioned. It must be confessed, however, that very fre- 
quently, perhaps in the majority of cases, no immediate cause can be 



96 DISEASES OF THE BRAIN. 

reasonably alleged. Of the three hundred and eighty-three cas^s noted 
by myself, no cause was noted in two hundred and ten. 

Relative to the influence of sleep, I am by no means in accord with 
those authors who regard it as a powerful exciting cause. During sleep 
the quantity of blood circulating in the cerebral blood-vessels is dimin- 
ished, and hence there is less tension upon their walls than during wake- 
fulness. I doubt very much whether cerebral haemorrhage ever occurs 
during healthy, undisturbed sleep. 

But there is a condition which supervenes upon sleep, and which, to 
ordinary observers, presents the usual phenomena of sleep, but which is 
really a very different state, both as regards the brain and the symp- 
toms — and that is stupor due to venous congestion. In this affection 
there is an increase of the pressure upon the brain, produced by the. over- 
distended vessels; and hence coma, to some extent, ensues. This state 
is characterized by difficulty of awaking the individual, by turgescence 
of the larger veins of the neck, by a more or less purple hue of the face, 
by snoring, and by the puffing out of the lips and cheeks in breathing. 
Both of these latter phenomena are due to paralysis. 

In this condition it is not unusual for cerebral hemorrhage to occur, 
but the existing state is not sleep. 

So far as my own experience extends, I have not found a majority of 
the cases, where I have examined into this point, to have taken place 
either during sleep or the stupor to which I have referred. I have made 
it a rule, not only in those cases of cerebral haemorrhage which have been 
under my own care, but all others, in which I could do so, to inquire 
particularly with reference to the matter in question, and have found 
that, in three hundred and eighty -five out of four hundred and sixty- 
seven cases, the individuals were awake at the time of the attack. 

Doubtless much of the confusion has arisen, not only from the non- 
discrimination of sleep from stupor, but also from treating of apoplexy 
as a disease instead of regarding it as a symptom due to several very 
different pathological conditions of which cerebral haemorrhage is only 
one, and of which embolism, thrombosis, congestion, meningeal haem- 
orrhage, and epilepsy, are others. 

Finally, it may be said of the etiology, that whatever tends to in- 
crease the flow of blood to the head, or to retard its exit, is capable of 
acting as an immediate cause of cerebral haemorrhage. 

Diagnosis. — The diagnosis of cerebral haemorrhage is ordinarily not 
difficult, but it must be confessed that one or two affections are very 
liable to be confounded with it, and the attendant circumstances sur- 
rounding a patient in a condition of insensibility may be such as to 
materially increase the obstacles to the formation of a correct opinion. 

Thus, supposing an individual to be found in a state of profound in- 
sensibility, the condition may be due to compression from injury of the 
skull, to concussion from a fall or blow, to congestion, to asphyxia, to 



CEREBRAL HEMORRHAGE. 97 

syncope, to a recent epileptic fit, to uremic intoxication, to hysteria, to 
narcotism, or to drunkenness. 

A mistake of either of these states for cerebral haemorrhage would 
be, in the end, embarrassing to the physician, and perhaps injurious to 
the patient. 

The coma might also be the result of embolism, of thrombosis, of 
tumor, of abscess, or of meningeal haemorrhage ; but, as regards these 
conditions, no opprobrium could be attached to the physician, or harm 
come to the patient, by any error of diagnosis, although a regard for 
scientific exactness should always prompt us to be as specific as possible 
in our inquiries and examinations. 

From asphyxia, cerebral haemorrhage is distinguished by the fact 
that in the former the respiration is suspended. The cause is often 
apparent. A careful examination of the cranium, and a survey of the 
surrounding circumstances, will enable the physician to ascertain the 
existence or non-existence of compression from traumatic cause. This 
cause may either be depression of bone, the rupture of an internal 
blood-vessel, or the entrance of some foreign body, as a bullet, into the 
interior of the skull. So far as symptoms are concerned, there might 
be considerable difficulty in diagnosticating either of these accidents 
from cerebral haemorrhage, but the history would render a mistake im- 
possible. 

Concussion presents more difficulties, because the comatose person 
may be found in such a situation as to warrant the opinion that he has 
fallen from a height, or otherwise received a blow on the head, when in 
fact he is suffering from cerebral haemorrhage. But if he has fallen from 
a height or been struck, there will probably be more severe bruises about 
his person than if he is affected with cerebral haemorrhage, and there may 
be bleeding from the ears or nose — symptoms of cranial injury not met 
with in the latter condition. 

If, however, the individual has fallen from a height, he may have 
done so in consequence of an extravasation of blood in his brain, and 
ae may present all the marks of suffering simply from the concussion, 
or he may have fractured skull with compression. It is, therefore, im- 
possible to make a correct diagnosis in all cases, or to lay down any 
certain rules which will constitute infallible guides. It is perfectly 
possible to meet with cases such as those referred to, in regard to which 
no human judgment can be certainly correct. Such instances are of 
course rare, and accordingly, in the great majority, the circumstances and 
the presumption will generally lead to a correct opinion. 

From congestion of the apoplectiform variety cerebral haemorrhage 
can generally be distinguished without much difficulty. The absence of 
stertorous breathing, the short duration of the coma, the transient 
character of the paralysis, the contraction of the pupils, the fact that 
the loss of sensibilitv and the power of motion are not generally confined 
8 



98 DISEASES OF THE BRAIN. 

to one side of the body, and the longer continuance of premonitory 
symptoms, will be sufficient indications of the existence of congestion. 
Syncope is distinguished by the circumstances that the respiration and 
circulation are both diminished in power if not suspended, that there is 
no hemiplegia, that the face is pale, the skin cold, and that these phe- 
nomena are all transitory in character. The history of the case will also 
assist us in arriving at a correct judgment. 

Epilepsy, if seen from the beginning of the paroxysm, cannot be 
mistaken for cerebral haemorrhage, nor this latter for epilepsy, if the 
onset of the attack has been witnessed. Even if there are convulsions 
present in the apoplectic seizure, the error could not readily be com- 
mitted if attention be paid to the attendant phenomena. For there is 
no biting of the tongue, the convulsions are persistent, and the animal 
heat is lowered, whereas in epilepsy the temperature rises at once and 
remains high — 105° Fahr. or thereabouts, during the convulsive stage. 
But the person found in a comatose condition, with no previous history 
to guide us, may be supposed to be either in the comatose stage of an 
epileptic paroxysm, or to be laboring under a seizure due to extravasa- 
tion of blood. In such a case, if the fit has been epileptic, foam will 
be found around the mouth, and perhaps blood from injury of the 
tongue or cheek. Moreover, the stupor of epilepsy is not usually of long 
duration, and is not generally characterized by stertorous breathing. 

In uraemia, the coma of which is very similar to that resulting from 
cerebral haemorrhage, the history of the case is our chief reliance for a 
correct diagnosis, though the absence of hemiplegia and the genera] 
presence of anasarca are of course of great value. Moreover, in very 
doubtful cases the urine may be drawn off by the catheter, and exam- 
ined for albumen and tube-casts. If these are present, the probability 
of the stupor being due to Bright's disease and uraemic intoxication is 
very much increased. The fact, also, that in uraemia there is a pro- 
gressive fall of the animal temperature — as low as 91.5° Fahr. being 
reached — and that there is no subsequent elevation, are important 
points in this connection. 

Coma is sometimes a manifestation of hysteria, but a very little 
acquaintance with the phenomena of this condition will suffice to pre- 
vent mistakes. In some cases of hysterical coma there is well-marked 
hemiplegia; but even when this complication is present, the facts that 
the hysterical diathesis exists, that there have probably been other mani- 
festations of hysteria, that the pulse is small, weak, and frequent, and 
that the breathing is free from stertor, will enable a correct diagnosis 
to be formed. 

In narcotism the condition often bears a close resemblance to that 
due to cerebral haemorrhage. But in the former there is no hemiplegia, 
the pupils are generally contracted, the respiration is not stertorous, 
and the coma comes on gradually. 



CEREBRAL HEMORRHAGE. 99 

Drunkenness and cerebral ha3morrhage are often confounded. I have 
known some sad mistakes of the kind to be made, both by professional 
and non-professional persons, many of which were unavoidable, for it 
must be confessed that there are great difficulties connected with the 
subject. The habit of drinking alcoholic liquors is so general that no 
reliance can be placed upon the test of smelling the breath. A person 
may have just taken a glass of wine or of brandy, and be seized with 
extravasation of blood in his brain immediately afterward, and when not 
in the least intoxicated. And, even if dead-drunk, he may at the same 
time have cerebral haemorrhage. In such a case as the latter, discrimi- 
nation would be impossible. In ordinary cases of alcoholic intoxication 
the patient can generally be roused to some extent; the pupils are 
dilated, but this latter is often the case in haemorrhage; the breathing 
is usually free from stertor, but some drunkards always snore; the pulse 
is small and weak, and there is no hemiplegia. When all these symptoms 
are in accord, there will be little difficulty; when they are not, the 
physician must be guarded in his expressions of opinion, and diligently 
inquire into the personal characteristics of the patient and all matters 
bearing on the history of the case. 

From the centric diseases previously mentioned, the diagnosis of 
cerebral haemorrhage is easy as regards some, and difficult as to others, 
Thus, from embolism it cannot in many cases be distinguished in the 
first stage. But when all the phenomena are taken into consideration 
the chance of error is very much diminished. Embolism is generally 
accompanied with disease of the left side of the heart, and there is often 
a history of rheumatism ; there are never any premonitory head-symp- 
toms ; it occurs in young persons as well as old ; for reasons which will 
be explained when the subject of partial cerebral anaemia from embolism 
is considered, the resulting hemiplegia is generally on the right side ; 
the paralysis usually disappears in a few hours after the attack ; if it 
does not, there is no gradual improvement, as in cerebral haemorrhage ; 
there are no contractions or partial convulsions 1 ; there are slight or 
no changes of temperature ; and there is more frequently delirium. 

The gradual development of the symptoms in thrombosis, tumor or 
abscess, and the frequency with which convulsions ensue in the latter 
diseases, together with the associated symptoms, will prevent the coma 
which sometimes exists being mistaken for the stupor of cerebral haem- 
orrhage. 

During the subsequent stages of cerebral haemorrhage, when the 
mental condition and the hemiplegia are the most prominent features, 
inquiry into the antecedent history will bring out the foregoing points, 
and assist us in arriving at a correct idea of the cause. Even, however, 

1 Jaccoud {op. cit, p. 141) so asserts, though I have seen one case in which post- 
mortem examination revealed the presence of an embolus in the middle cerebral artery, 
and in which there had been convulsions. 



100 DISEASES OF THE BBAIX. 

should we be baffled in this respect, no great inconvenience could result 
either to the patient or physician. 

Prognosis. — The prognosis depends upon the extent or situation of 
the haemorrhage, and refers to the probability of saving life during the 
period of attack and immediately afterward, and of curing or mitigating 
the subsequent paralysis. 

In the severe apoplectic form, death is almost inevitable; so far as 
my experience goes, it is the invariable result. It generally takes place 
within a few hours. If, however, life be prolonged till the fourth day, 
there is some hope. Irregularity of pulse, or one very rapid, impossi- 
bility of swallowing, involuntary evacuation of the faeces, and cold 
sweats, render, if possible, the prognosis still more unfavorable. 

In the apoplectic form attended with paralysis, the gradual increase 
of the coma and hemiplegia indicate the continuance of the haemor- 
rhage, and are consequently of grave importance. About one-third of 
those attacked with this form die. The prognosis is bad in proportion 
to the debility and age of the patient, and the circumstances under 
which the attack has occurred. Thus, if it has supervened in a person 
who has had no obvious exciting cause, the probability is that there is 
serious disease of the blood-vessels, whereas, coming on in a young per- 
son as the result of severe muscular exercise, or mental strain, the prog- 
nosis is more favorable. A second attack is more apt to prove fatal 
than a first, and a third than a second, and so on. 

In the mild form characterized by paralysis, but no loss of conscious- 
ness, the prognosis is generally favorable. It must be recollected, how- 
ever, that the risk of inflammation is quite great, both in this and the 
apoplectic form with paralysis, and that the patient is not safe from it 
till after the eighth day. 

And in both forms, if the temperature rise above 100° Fahr. ; if the 
respiration be chiefly abdominal; if the patient is unable to swallow; 
and rattling of mucus is heard in the throat, the prospect of recovery is 
bad. The same may be said of pain in the head and contractions of the 
paralyzed muscles. If, further, as Bourneville has shown, the tempera- 
ture reaches 104° Fahr., death is inevitable. 

As regards the probability of recovery from the paralysis, much de- 
pends upon the opportunities the patient may have for receiving proper 
medical treatment. The tendency is generally toward amendment even 
in the worst cases. Gradually the speech improves, the breathing be- 
comes better, and the arm acquires more strength; but the improve- 
ment often stops here, and never goes on unaided to complete recovery. 
The longer the paralysis has lasted, the less prospect there is of great 
progress under any treatment; and, if strong contractions producing 
distortions have taken place, the prognosis is unfavorable. 

Certain muscles re over better than others. The extensors of the 



CEREBRAL HEMORRHAGE. 101 

foot and hand are especially intractable, but, as a rule, those of the 
lower extremity improve more rapidly than those of the upper. 

The mind ordinarily improves, pari passu with the physical symp- 
toms, though not always. I have witnessed several exceptions to the 
rule. Even in slight cases the intellect may suffer to a great extent, 
and in no case is it ever in all respects as good as before the attack. 
Among the unfavorable signs are, persistent irritability of temper, fail- 
ure of memory, and the existence of delusions. Difficulties of speech, 
whether as regards the memory of words, or the ability to coordinate 
the muscles of speech, so as to pronounce them properly, are often very 
persistent. I have now under my care a gentleman who was attacked 
with cerebral haemorrhage two years ago, whose physical powers are 
quite good, and whose mind is not seriously impaired, but who cannot 
yet remember sufficient words to carry on an ordinary conversation. 
When the difficulty is simply due to paralysis of the tongue and facial 
muscles, the prognosis is more favorable. 

Morbid Anatomy. — The seat of the extravasation from cerebral haem- 
orrhage may be in the substance of the cerebral tissue, or in the ven- 
tricles. The former is much the more common. 

Now, the blood, which is poured out from a ruptured vessel into the 
substance of the brain must, of course, occupy its place by separating 
or lacerating the fibres. It thus forms for itself a cavity, which en- 
larges as the haemorrhage goes on, until at last the resistance to further 
separation or laceration may be so great as to overcome the tension of 
the blood, and thus put a stop to the bleeding. 

The shape of the cavity varies according to the manner by which it 
has been produced. When it is formed by the separation of the cere- 
bral fibres, it is generally elongated ; whereas, when produced by lacera- 
tion, it is oval, round, or irregular in form. The situation of the haem- 
orrhage modifies the form of the cavity. In the hemisphere it is usually 
round; in the motor tract, irregular or oval. The variations as regards 
size are great. I have seen clots no larger than a pea, and again as 
large as an orange. When haemorrhage occurs in the motor tract, the 
clot is almost invariably small; whereas, in the hemispheres, in the cere- 
bellum, or in the ventricles, it is large. 

A clot does not always consist of blood alone. Brain-tissue is very 
often mixed with it, and this is especially the case when the extravasa- 
tion has been into the white substance of the hemispheres. 

Gintrac * has collected the data of five hundred and sixty cases of 
cerebral haemorrhage, in which there was a single clot, and in these the 
seat of the extravasation is shown in the following table : 

1 " Traite theorique et pratique des maladies de l'appareil nerveux '' Tome deuxiSme 
Paris, 1869. Art " Hemorrhages du cerveau." 



102 DISEASES OF THE BRAIN. 

Corpora striata 72 

Optic thalaini 38 

Corpora striata and optic thalami simultaneously 48 

Middle lobes of the brain 127 

Pons- Varolii and crura cerebri 78 

Cerebellum 36 

Ventricles 46 

Posterior lobes of the brain 33 

Anterior lobes of the brain 17 

Medulla oblongata 2 

Corpus callosum 1 

Cortical substance of the brain 45 

Total 560 

The ordinary seat of cerebral haemorrhage is thus seen to be in the 
vicinity of the motor tract, for in nearly one-half of the total number 
of cases the lesion was situated either in the corpora striata, the optic 
thalami, the pons Varolii, the crura cerebri, or the medulla oblongata. 
And of these parts the corpora striata and optic thalami are preemi- 
nently liable. As the lesion is seldom confined to these organs, the in- 
ternal capsule rarely escapes injury. Next in order of frequency come 
the middle lobes. 

In the great majority of the cases of cerebral haemorrhage the lesion 
is situated primarily in the gray substance. This is probably due to 
the fact of the greater vascularity which this tissue possesses. It 
would appear, too, that even when the extravasation is not into the 
corpus striatum or optic thalamus, it is very apt to be in the immediate 
vicinity of these organs. M. Duret * has given an anatomical expla- 
nation of this fact, which appears to be satisfactory. According to this 
observer, the arteries of the corpus striatum, which are given off gen- 
erally from the middle cerebral artery, though sometimes from the 
anterior cerebral, enter the brain through the anterior perforated space. 
A few delicate branches go to the caudate nucleus of the corpus stri- 
atum, but the larger ramifications are distributed sometimes to the 
lenticular nucleus, but more generally they wind around this organ, 
and give origin to branches which are widely distributed, reaching 
even as far as the island of Reil. Thus the largest intra-cerebral 
arteries are situated in the external portion of the corpus striatum. 
And this is the exact place where, according to Charcot, cerebral 
haemorrhage is most apt to occur. 

Gendrin 2 had previously remarked that the extravasation in cases 
of cerebral haemorrhage almost always comes from the branches of the 
middle cerebral artery. The middle lobe, the island of Reil, the coitus 
striatum, and the optic thalamus are nourished through this vessel, and 

1 " Note sur la distribution des arteres nourrieieres du cerveau." Mouvement me- 
dical, 1873, p. 27. Also, "Recherches anatomiques sur la circulation de l'encephalc." 
Archives de physiologic, 1874, p. 316. 

2 " Traite philosophique de medecine pratique.'' Paris, 1838, tome L, p. 448. 



CEREBRAL HAEMORRHAGE. 103 

hence the great preponderance of extravasation in these portions of 
the encephalic mass. 

It has also been observed — and Durand-Fardel l calls special atten- 
tion to the circumstance — that cerebral haemorrhage has a manifest ten* 
dency to be developed and directed, rather toward the central than the 
peripheral parts of the brain. It is thus, to say, centripetal in its course, 
in which respect it differs from cerebral softening, which is not less 
evidently centrifugal — the peripheral regions showing a greater ten- 
dency than the central to be affected by this morbid process. 

The right side of the brain appears to be more frequently the seat of 
cerebral haemorrhage than the left. Thus, on consulting Gintrac, 2 we 
find that in three hundred and sixty-nine cases in which the side on 
which the lesion was situated was noted, the parts were affected in 
the order of frequency shown in the following table : 

Eight. Left. 

Corpus striatum, optic thalamus, and these bodies simultaneously 73 63 

Middle lobes 63 52 

Pons Varolii 10 10 

Cerebellum 14 12 

Cortical substance 15 8 

Posterior lobes 18 15 

Anterior lobes 6 10 

Total 199 170 

The right side had thus a numerical superiority of twenty-nine over 
the left. It will be observed, also, that in no one part did the left side 
predominate except in the case of the anterior lobe. On the other hand, 
Durand-Fardel, 3 from an examination of one hundred and seventeen 
cases of haemorrhage into the hemispheres, found that the right side was 
the seat in forty-nine, the left in fifty-seven, and both sides in eleven in- 
stances. Of eleven cases of cerebellar haemorrhage, the right lobe was 
affected six, the left five times, and the middle lobe twice. 

Generally there is but one recent extravasation, but occasionally two 
or more occur simultaneously, or at least so near to each other in point 
of time as to be essentially contemporaneous acts of one morbid pro- 
cess. Of one hundred and thirty-nine cases cited by Durand-Fardel, 4 
twenty-one were multiple ; eighteen of these were double, and three 
triple. In my own experience two cases of triple lesions have occurred, 
and two of double lesions. Of the triple cases the right corpus stria- 
tum, right middle lobe, and left middle lobe, were the seats in one, and 
the right and left corpora striata, and left anterior lobe, in the other. 
Of the double cases the seats in one were the right corpus striatum, 
and right middle lobe, and in the other the right middle and posterior 
lobe and right half of the pons Varolii. 

1 " Traite pratique des maladies des vieillards." Paris, 1873, p. 181. 

2 Op. et loc. tit. • Op. tit., p. 185. 4 Op. tit., p. 186. 



104 DISEASES OF THE BRAIN. 

It sometimes happens that the mass of extravasated blood breaks 
through the cortical substance of the brain, and appears immediately 
under the pia mater and arachnoid; or these membranes may give way, 
and the blood be effused into the space between them and the dura 
mater. In a very few of these cases the blood comes primarily from 
the cortical substance of the brain, but in the greater number the ex- 
travasation originates more deeply and reaches the surface by lacer- 
ating the easily-torn white tissue. The blood in these cases undergoes 
coagulation much more rapidly than when it remains in the cerebral 
substance, unless the base of the brain be the seat, in which case it often 
remains fluid. 

The extravasation takes place into the ventricles in about one-half 
of all the cases. The lateral or fourth ventricle may be the seat, or 
it may exist in both of the former. The blood extravasated into the 
ventricles remains liquid a longer time than when effused into any 
other part. This is probably due to the fact that it is subjected to the 
action of the ventricular fluid, by which its physical properties are 
altered. 

In the majority of cases of haemorrhage into the ventricles, the 
blood comes originally from the corpus striatum, or optic thalamus, 
but it may also be derived from the choroid plexus, from the septum 
lucidum, or from the walls of the ventricles. Sometimes it is im- 
possible to determine its point of origin. It may enter the ventricle 
through a small opening, in which case the foyer is distinct, or the 
wall of the ventricle may be largely lacerated and so broken down that 
the foyer and the ventricle constitute essentially but one cavity. The 
septum lucidum is not infrequently torn, and the two lateral ventricles 
are thus converted into one cavity. 

As regards what may be called the secondary consequences of an 
extravasation of blood into the cerebral substances, we find that when 
it is large the convolutions are flattened against the walls of the cranium, 
the membranes are usually dry, and a distinct feeling of fluctuation can 
often be detected. In several cases I have known a large extravasation 
to cause by its own weight a complete rupture of the lobe in which it 
existed, through the handling required in removing the brain from the 
skull. . 

At other times the membranes are evidently congested; the brain- 
tissue, when incised, exhibits an increased number of red points, and the 
subarachnoidean or ventricular liquid may be largely augmented over 
the normal quantity. 

The state of the arteries is a most important and interesting subject 
for examination, but, as it has an immediate and direct relation with 
the pathogeny of cerebral haemorrhage, it will be more properly consid- 
ered under the head of pathology. 

Extravasated blood undergoes certain changes. Instead of di- 



CEREBRAL HEMORRHAGE. 105 

viding into two parts, the clot and the serum, as does blood when 
exposed to the atmosphere, it remains for a time homogeneous and 
gelatiniform. About the fifth or sixth day it separates into two parts ; 
the one, the serum, is absorbed by the surrounding tissue; the other, 
consisting mainly of the fibrine and the red corpuscles, contracts and 
becomes hard. By the fifteenth day it has become fibrinous in texture, 
and is changed from its former black hue to a yellow color. Micro- 
scopic examination, made at any period during these changes, reveals 
the presence of red corpuscles, crystals of hematoidin and sometimes of 
cholestrin. It never entirely disappears. 

In the earlier period of the extravasation, the walls of the cavity 
are rough, and discolored with blood. But, as the changes are going 
on in the clot, the walls likewise alter in appearance ; the inequalities 
and irregularities disappear, and a new formation of connective tissue 
lines the cavity. Blood-vessels appear in it, and aid in the absorption 
of the fluid portion of the extravasated blood. As the process of 
separation and absorption goes on, the cavity contracts upon its con- 
tents, and eventually forms a cicatrix which incloses the remains of 
the clot. This cicatrix is generally of a yellow color, and firm in 
texture. 

Sometimes, however, absorption does not take place. The con- 
traction of the walls of the cavity does not therefore ensue, and it 
remains distended with more or less altered blood. This may be the 
starting-point of secondary lesions, or a new haemorrhage may occur 
into the same cavity, or an abscess may result. 

Pathology, — The theory of cerebral haemorrhage brings us to the 
consideration of several important points. One of the first questions 
to be solved is, Can the rupture of a vessel of the brain take place — 
not including traumatic causes — unless the vessel is in a diseased 
condition ? Both sides of this proposition have their adherents. On 
the one part, it is urged that cerebral haemorrhage never takes place 
spontaneously unless the walls of the bleeding vessel have been so 
injured by disease as to destroy their strength and elasticity ; on the 
other, that it is perfectly possible for a blood-vessel to give way, owing 
to the increased tension of the blood or disease of the peri-vascular 
tissue, without the walls of the vessel itself being in the least diseased. 
While admitting that, in the majority of cases, the structure of the 
yielding vessel will be found to be impaired, I am satisfied that either 
of the other two causes may produce a rupture. The reasons for this 
opinion will be apparent in the course of the following remarks. 

One of the most common diseases to which the cerebral arteries are 
liable is chronic endarteritis, a condition which has been well described 
by Virchow, 1 and which is particularly apt to be met with in those who, 

1 " Ucber die Erweiterimg kleinerer Gefasse." Archiv fur path. Anat, und Physiol., 
B. III., 184S, and " Cellular-pathologie," Berlin, 1871, S. 458 et scq. 



106 DISEASES OF THE BRAIN. 

from age or other debilitating influence, have had their nutrition 
impaired. As the consequence of this state, the vessels lose their 
elasticity, become brittle, and are therefore often unable to bear 
the ordinary tension of .the blood, much less any severe strain. 

This disease may terminate in fatty degeneration of the arterial 
Avails, or this last condition may be the primary affection. Fatty 
degeneration, like chronic endarteritis, is most commonly met with 
in badly-nourished persons, but who are at the same time cachectic. 
The inner coat is the point of origin, and hence it sometimes hap- 
pens that this and the middle coat give way, leaving the external 
coat entire, and thus forming an aneurism. But Bouchard, 1 who 
has examined into this matter with great minuteness, denies that 
such aneurisms are ever found, and asserts that the so-called aneuris- 
mal sac consists of the lymphatic membrane, lining the cavity in the 
perivascular tissue, through which the vessel passes ; and that the 
blood, in such cases, has already ruptured the vessel. In reality, how- 
ever, there is no haemorrhage into the cerebral tissue till this mem- 
brane gives way. 

In a subsequent memoir, by MM. Charcot and Bouchard, 2 this point 
is still more thoroughly considered, and the opinion expressed that cere- 
bral haemorrhage is almost invariably due to what they call miliary 
aneurisms, which are the result of arteritis, and which are not neces- 
sarily preceded by atheroma. 

The existence of these minute aneurisms was first pointed out by 
Cruveilhier, 8 and was subsequently recognized by Calmeil. 4 Meynert '' 
appears also to have noticed them, and Heschel 6 discovered them in the 
pons Varolii; but no one previous to Charcot and Bouchard called at- 
tention to the relation which they bear to cerebral haemorrhage. On 
March 16, 1866, while examining the foyer of a recent extravasation 
into the brain, they perceived, on the walls of the cavity in the cerebral 
tissue, two small globular masses attached to a minute vessel. These 
were miliary aneurisms. One was ruptured, and its contents were in 
immediate relation with the mass of extravasated blood constituting the 
apoplectic clot. Previously to this time these observers had noticed 
these aneurisms, but not before had they associated them with the 
pathogeny of cerebral haemorrhage ; since then, in numerous commu- 

1 " Etudes sur quclques pointes de la pathogenic dcs hemorrhagies cerebralcs." 
Paris, 1866. 

2 " Nouvelles recherches sur la pathogenie de l'hernorrhage cerebrale." Archives de 
physiohgie normale et pathologiqite, 186S, pp. 110-643. 

3 " Anatomie pathologique du corps humain," liv. xxxiii., PI. 2, Fig. 3. 

4 "Traits des maladies inflammatoires du cerveau." Paris, 1859, torue ii., p. 522. 

5 " Ueber Gefassentartungen in der Yarolsbriicke und den Gebirnschenkelm." 
Allgemelne Wiener Wochenschrift, No. 28, 1864. 

6 " Die Capillar-Aneurysmen ira Tons Varolii." Wiener mcdicinische Woehenschrift^ 
September, 1865. 



CEREBRAL HEMORRHAGE: 



107 



nications, they have called attention to the importance of their dis- 
covery, and its value is generally acknowledged by neuro-pathologists. 



Fig. 8. 




<-l^"' 



In the accompanying woodcut (Fig. 8), taken from Bouchard's mem- 
oir, is represented one of these aneurisms which has been ruptured 



Fig. 9. 




into a hemorrhagic clot : a, the aneurism ; h, the clot ; c, c, the torn 
perivascular or lymphatic sheath. 

Fig. 9 is from the drawing of a vessel which I recently dissect- 
ed out of the pons Varolii, into the right lobe of which a large ex- 



108 DISEASES OF THE BRAIN. 

travasation had taken place. Both lobes were studded with these 
aneurisms ; they were also found in the convolutions in the optic 
thalami and corpora striata, and in the white substance of both hemi- 
spheres ; a large extravasation had also taken place into the right 
hemisphere. 

Id sixty-nine cases of cerebral haemorrhage in which post-mor- 
tem examinations were made, atheroma was found but in fifteen, 
or twenty-two per cent., while these miliary aneurisms were met 
with in every case. They appear as little globular masses in the 
small intracranial vessels, and are in size from one-tenth of a milli- 
metre to one millimetre. If they contain liquid blood, they are 
red ; but if the blood be coagulated, the color is dark, almost black 
in some cases. In the order of frequency, they are found in the 
optic thalami, the corpora striata, the convolutions, the tuber annu- 
lare, the cerebellum, the centrum ovale, the crura cerebri, and the 
medulla oblongata. 

According to Charcot and Bouchard, the arteritis, which re- 
sults in the formation of these aneurisms, is diffuse in charac- 
ter. It is found not only in the minute artery, which is the sub- 
ject of the aneurismal dilatation, but extends to the entire system 
of minute intracranial vessels. This arteritis is in some respects 
analogous with what Rokitansky described under the name of chronic 
peri-arteritis, and is characterized by disease of the membrane, desig- 
nated by Robin as the perivascular sheath, and by His as the lym- 
phatic sheath. There are also lesions of the adventitious tunic and 
of the muscular and internal coats. The diseased action proceeds 
from without inward, and hence the name of peri-arteritis is a very 
proper one. 

Charcot and Bouchard claim that, with the following exceptions, 
all cases of cerebral haemorrhage are the result of the rupture of 
miliary aneurisms, viz., fracture with depression ; the haemorrhages 
which result from thrombosis of the sinuses, and those which occur in 
the course of certain depraved states of the system. While admit- 
ting that the majority of cases of cerebral haemorrhage have this 
origin, I am not prepared to go so far as these observers in ascrib- 
ing all not embraced in the three categories of exceptions above 
specified, as being due to this cause. I had recently the opportu- 
nity of convincing myself that this explanation of the pathogeny of 
cerebral haemorrhage is too absolute ; for, on examining the brain of 
a patient who had died from an extravasation of blood into the left 
corpus striatum, optic thalamus, and left lateral ventricle, not a sin- 
gle miliary aneurism could be discovered, although they were care- 
fully sought for in all parts of the brain. The patient, a lady forty- 
three years of age, had suffered from repeated attacks of acute 
rheumatism, had frequently been affected with headache and ver- 



CEREBRAL HEMORRHAGE. 109 

tigo, and bad been seized witb apoplexy wbile in tbe water-closet. 
She bad been the subject of heart-disease for over twenty years. I 
bad only the brain submitted to me for examination, but all the arte- 
ries of this organ were in a state of atheromatous degeneration, and I 
was able to find what appeared to be the vessel, or one of them, wbich 
had given way and produced the extravasation. The accompanying 
engraving (Fig. 10) represents this artery as seen witb an incb object- 
ive. It is perceived that several of the aneurismal dilatations have 
given way ; tbe internal coat of this, as well as of other arteries, was 

Fig. 10. 




found, by microscopical examination, to be in a state of fatty degen- 
eration; the same state existed in the middle coat, and the external 
coat was thickened and friable. 

Lancereaux * reports a very similar case, of which, as it has an im- 
portant bearing on the subject, I quote the summary which he gives 
(page 424) : 

" Haemorrhage into the left " [right is evidently meant, and it is so 
stated on page 252, where the full report of the case is given] " corpus 
striatum, producing an irruption into the lateral ventricles, and arteritis, 
albuminuria, cardiac hypertrophy. 

" A woman, aged fifty-eight, died a few days after an attack charac- 
terized by left hemiplegia, diminution of sensibility, and vomiting. The 
autopsy revealed the existence of a hsemorrhagic clot at the exterior 
and posterior part of the corpus striatum, which, after having separated 
this ganglion from the optic thalamus, had broken into the ventricular 
cavity. The nervous tissue, besides being torn, was colored yellow, 
through the infiltration of hsematine into its substance. The ventricles 
contained a small quantity of liquid blood. There existed under the 
ependyma of the posterior cornu of the right ventricle a hsemorrhagic 
punctation, and a sanguineous suffusion extended over the whole cir- 
cumference of the cerebellum. The entire encephalic mass was injected. 
The walls of the cerebral arteries were thick and opaque. On the 

1 "Anatomie pathologique," texte, pp. 252 and 424; atlas, plates 24 and 43. 



110 DISEASES OF THE BHAIN. 

branches, even those of the smallest size, were perceived moniliferous 
dilatations, the result of a primitive alteration of the arterial wall, 
and the probable points of origin of the haemorrhage. The aorta 
was affected with endarteritis throughout its whole extent, the aortic 
orifice was slightly insufficient, and the left ventricle was markedly 
hypertrophied ; the renal arteries were indurated, rigid, and calca- 
reous. The kidneys, small, atrophied, and granular, were affected 
with interstitial nephritis. The arterial system was involved through- 
out almost its entire extent." 

It would appear, therefore, that we cannot set aside the results ob- 
tained by Virchow and others, and that, in the present state of our 
knowledge, it is safe to adopt the opinion expressed by Durand-Fardel, 2 
that, although " the facts observed as described by MM. Charcot and 
Bouchard have undoubted value, it would, nevertheless, be premature 
to attribute to miliary aneurisms an exclusive part in the production of 
cerebral haemorrhage." 

The condition of the perivascular tissue, or the brain-substance, has 
much to do with the occurrence of haemorrhage. One reason why ex- 
travasation more frequently occurs in the brain than in the liver, for 
instance, is, that its tissue is softer, and therefore not capable of giving 
as much support to the blood-vessels as is the latter organ. Now, when 
the cerebral substance is softened by disease in any part, the natural 
support of the vessels of that part is still further lessened, and the ten- 
dency to haemorrhage increased. Again, in the condition sometimes 
met with in old people, in which the brain becomes atrophied, the ves- 
sels may undergo dilatation and subsequent rupture. This view is op- 
posed by Jaccoud, 2 but in one case of cerebral haemorrhage, terminating 
in death, and in which I had the opportunity of making a post-mortem 
examination, the right hemisphere, the seat of the extravasation, was 
very considerably atrophied, and weighed three, ounces and a quarter 
less than the left. The possibility of the existence of this cause may, 
therefore, be admitted, although it cannot be considered as definitely 
established. The researches of Cotard 3 would appear to show that cere- 
bral haemorrhage is not infrequently a cause of partial atrophy of the 
brain. 

In the next place, the state of the blood, as regards quality and 
tension, must be considered. There can be no doubt that certain dis- 
eases affecting the general system may so deteriorate the blood as to 
render it unfit to properly nourish the blood-vessels, and hence their 
tissue is more readily broken down. Among these conditions are 
typhus, scurvy, chlorosis, gout, and syphilis. 

The tension of the blood in the vessels is subject to constant va- 

1 Op. cit., p. 262, 

2 Op. cit., p. 155. 

3 "Etude sur l'atrophie partielle du cerveau," Paris, 1868. 



CEREBRAL HAEMORRHAGE. Ill 

nation from the operation of many physical and mental causes, and 
may, through their action, be so increased as to overcome the resist- 
ance afforded by the vascular Avails. These influences have been suf- 
ficiently considered in the section on causes, and need not, therefore, 
be dwelt upon here at any length. My own opinion of their sufficien- 
cy, without preexisting disease of the blood-vessels, to produce rupt- 
ure and extravasation, has been formed after much observation 
and reflection. Analogous phenomena take place every day, and are 
not supposed to be due, in any extent, to vascular disease. Thus 
nasal haemorrhage occurs from strong muscular exertion of such a 
character as to retard the flow of blood from the brain, from emo- 
tional or other kind of mental excitement, and from hypertrophy 
of the left side of the heart, by which the amount of blood in the 
cerebral vessels is increased. All these causes augment the tension, 
and it would be singular if at times a healthy intracranial vessel 
did not give way through their influence, as well as one outside of 
the skull. 

Differential Diagnosis. — A point of very great importance re- 
mains to be considered as a part of the pathology, and that is whether 
it is possible or not to determine during life in what part of the 
brain an extravasation has taken place. While I am afraid we can 
not be as explicit in this matter as is desirable, I am very sure 
we can often, from a careful study of the symptoms, arrive at con- 
clusions more or less accurate, and can sometimes determine the 
question with absolute certainty. The great difficulty is, that we 
are not yet sufficiently acquainted with th'e physiology of the sev- 
eral parts of the brain, and hence are not able to ascribe, with as 
much sureness as is desirable, variations from healthy action, to de- 
rangement of the proper anatomical part of the cerebral mass. Be- 
sides, when the extravasation is large, although it may be strictly 
confined to the anatomical limits of the ganglia or part of the en- 
cephalic mass in which it originates, it may act by transmitted press- 
ure upon contiguous ganglia or parts, and hence the symptoms are 
rendered complex. 

As we have seen, haemorrhage is more liable to take place within 
the ganglia bordering on the motor tract than any other part of the 
brain. This is mainly due to the fact that this is the most vascular 
part of the cerebral substance. 

Generally speaking, when the clot is strictly limited to either of 
the nuclei of the corpus striatum, the paralysis, however extensive it 
may have been in the first place, is of a transitory character. More- 
over, there is no tendency to the production of muscular contractions 
at a late period of the disease. 

And there are instances on record in which there has been extravasa- 
tion into the corpus striatum, and no paralysis of any part of the body. 



112 DISEASES OF THE BRAIN. 

Gintrac, 1 of forty cases collected by him, found apparent absence of 
paralysis in five. But he admits that this number may perhaps be re- 
duced, for one of the cases was that of an infant one day old, and the 
other, that of an old man eighty years of age, who had had a cerebral 
ha3morrhage ten years before his death, in both of which an exact di- 
agnosis of this point could not have been otherwise than difficult. But 
in one of the others there was no paralysis, and yet after death a clot 
as large as a pigeon's egg was discovered in the left corpus striatum. 
In the second there was no actual paralysis, but a weakness and trem- 
bling of the right arm. The post-mortem examination revealed the 
existence of a clot, as large as an almond, in the left corpus striatum. 
The third was for a few moments deprived of the power of speech, but 
he had equal muscular strength on both sides. Then he became weak 
and died, without having been actually paralyzed. After death a cav- 
ity filled with a brown serous fluid was found in the anterior and ex- 
ternal part of the right corpus striatum, and the whole of the left pos- 
terior lobe was reduced to a yellowish pulp, and was studded with 
purulent foyers. This was certainly not an uncomplicated case. And 
thus of the five there was but one in which there was indubitably no 
paralysis. 

The optic thalamus is another common seat of extravasation. In 
such a case the observed symptoms are especially connected with the 
organs of the special senses. Thus there are double vision, dilatation 
or convulsive movements of the pupil, blindness, and anaesthesia or 
hyperesthesia of the paralyzed parts of the body. As in lesions of the 
corpus striatum, the paralysis of motion, if present at all, is on the 
opposite side of the body, and is usually transient in character. The 
hearing and smell may also be affected. Luys 2 has collected a large 
number of cases in support of the view here enunciated. 

The researches of Virenque 3 also go to show that lesions of the 
optic thalamus are accompanied with loss of sensibility on the opposite 
side of the body. His observations, therefore, are entirely confirm- 
atory of those of Turck, 4 who in four very carefully recorded cases 
found hemi-anaesthesia coexistent with lesion of the optic thalamus 
and corpus striatum of the opposite side. 

In those cases of cerebral haemorrhage limited to the optic thala- 
mus, paralysis of motion when it exists is less intense than when the 
corpus striatum is also involved, and is often restricted to the inferior 
limbs. The speech is rarely involved. 

1 Op. cit, tome ii., p. 142 et seq. 2 Op. cit., p. 534 et seq. 

3 " De la perte de la sensibilite generale et speciale d'un cote du corps (hemianaesthe- 
siae) et de ses relations avec certaines lesions des centres opto-stries." Paris, 18*74. 

4 " Ueber die Beziehung gewissen Krankheitsberde des grossen Gehirns zur Anaes- 
tbesie." Sitzimgsbcrichte des Kais. Kon. Academie der Wissenschaften, Band xxxvi., 
1859. 



CEREBRAL HEMORRHAGE. 



113 



Fig. 11. 



The symptoms just detailed are more the result of lesions affect- 
ing adjacent regions than of the thalamus itself. The sensory division 
of the internal capsule and the optic tract are the parts most liable to 
be injured from haemorrhage in the thalamus. 

The intelligence is not notably lessened, but there is often a 
marked proclivity to the supervention of hallucinations of the special 
senses. Luys 1 has very thoroughly worked up this subject, 2 and 
Ritti has recently in a philosophical essay adduced many facts and 
arguments to show the relations of lesions of the optic thalamus 
with hallucinations. In thirty-two cases of hallucinations, mainly 
of the sight and hearing, but some- 
times of all the senses, post-mortem 
examinations revealed the existence 
of some kind of lesion of the optic 
thalami. 

It sometimes happens that an ex- 
travasation, originating in either the 
corpus striatum or optic thalamus, 
involves both these ganglia and the 
intervening part of the internal cap- 
sule. Hence we have, as the most 
common symptoms of haemorrhage 
of this character, loss or impairment 
of the power of motion, disturbance 
of sensibility, dilatation or irregular 
movements of the pupil, aberrations 
of vision and hearing, etc. 

As we have seen, a lesion of the 
posterior half of the internal capsule 
of one side produces loss of the power 
of motion and of sensibility in the 
opposite side of the body. The man- 
ner in which this is accomplished will 
be readily understood from an inspec- 
tion of the accompanying diagram 
(Fig. 11), in which a indicates the 
left internal capsule containing both 

motor and sensory fibres ; b the left half of the pons Varolii and me- 
dulla oblongata ; c the left lateral half of the spinal cord ; d a sensory 
nerve-fibre decussating soon after its entrance into the cord ; e a 
motor nerve-fibre decussating at the lower boundary of the medulla 
oblongata. A lesion existing at f will therefore cause paralysis cf 
motion and of sensibility at g, on the right side of the body. 




1 Op. et loc. cit. 

2 " Theorie physiologique de l'hallucination. 

9 



Paris, 1874. 



114 DISEASES OF THE BRAIN. 

When the extravasation beginning in the left optic thalamus or 
corpus striatum extends to the fissure of Sylvius so as to involve the 
posterior part of the third frontal convolution, the island of Reil, 
or other part supplied by the middle cerebral artery, or when it 
originates in this region, aberrations of speech occur. These are in- 
dependent of paralysis of the tongue, and are such as are embraced 
under the term aphasia. This subject will be hereafter more fully 
considered. 

If the lesion be limited to the anterior two-thirds of the posterior 
half of the internal capsule, there will be merely paralysis of motion, 
although there may be, as I have lately had occasion to know, slight 
and temporary hemi-anaesthesia. If, however, the posterior third of 
the posterior half of the internal capsule be the seat of the haemor- 
rhage, there will be well-marked hemi-anaesthesia. Of course there 
are in almost all cases various proportional combinations of loss of 
the power of motion and of sensibility according to the exact posi- 
tion of the lesion in the internal capsule. And it invariably happens 
that with all lesions of the motor tract late contractions of the op- 
posed muscles supervene. 

Haemorrhage into the crus cerebri produces hemiplegia of the 
opposite side, more or less extensive, according to the size of the clot, 
with loss of sensibility. The third pair arises in part from the crus, 
and hence may be paralyzed, producing ptosis and external strabis- 
mus on the side corresponding to the seat of the lesion, and conse- 
quently opposite to the hemiplegia. 

When the pons Varolii is affected, the crossed paralysis is still 
more marked. The limbs are paralyzed on the opposite side, and 
the face in whole or in part on the same side as that in which the 
haemorrhage takes place. If the extravasation is in the mesial line, 
both sides of the body are paralyzed. According to Trousseau, 1 how- 
ever, crossed paralysis is not always due to a lesion of the pons, as 
asserted by Gubler, 2 and as supported by additional cases collected 
by Luys. 3 Trousseau rests his opinion on one case, in which after 
death very extensive lesions of the brain were found, but none involv- 
ing the pons. 

Nevertheless we find in practice that when an extravasation of 
blood is confined to one side of the pons, and is not extensive, the 
face is paralyzed on the corresponding side. The facial nerve makes 
its exit from the side of the medulla oblongata ; some of its roots 
of origin can be traced as far as the floor of the fourth ventricle, 
others come from the lower part of the medulla oblongata, and others 

1 " Lectures on Clinical Medicine," Bazire's translation, Part II., p. 333. 

2 " Sur l'hemiplegie alterne," Gaz. hebd., October, 1856, and " Memoire sur les para- 
lysies alternes," etc., Gaz. hebd., 1859. 

3 Op. tit, p. 529 et seq. 



CEREBRAL HAEMORRHAGE. 



115 



Fig. 12. 



descend from the upper border of the pons, where they probably decus- 
sate. Now, a lesion existing in a lateral half of the pons will, there- 
fore, produce a paralysis of the corresponding facial nerve, and of the 
opposite spinal nerves; whereas, if 
it occur above the point of decus- 
sation of the encephalic fibres, the 
paralysis will be on the opposite 
side for all parts of the body. 
These facts are shown in the ac- 
companying diagram (Fig. 12). 

It is obvious, from a study of 
this diagram, that a lesion of one 
lateral half of the pons (at I) will 
cause paralysis of motion and of 
sensibility of the opposite side of 
the body generally, and of the cor- 
responding side of the face ; and 
that a lesion of the hemisphere 
(at m) will produce paralysis of 
the opposite side of the face and 
the body. 

It is true that it is not definite- 
ly settled by histological investiga- 
tion that the decussation of the 
ascending roots takes place, but 
pathology is just as capable of 
determining the question as his- 
tology. Vulpian ' asserts that the 
decussation of the roots of the 
facial occurs in the mesial line of 
the medulla oblongata at the junc- 
tion of the two nuclei of origin ; 

but, if this were the case, a lesion of one side of the pons would neces- 
sarily be followed by double facial paralysis, a sequence which does 
not in reality ensue. 

From the contiguity of the pons to the medulla oblongata, an ex- 
travasation of blood into it is generally accompanied by the symptoms 
which result from haemorrhage into this latter organ, though they are 
not as a rule so strongly marked. 

The principal phenomena indicating the medulla oblongata as the 
seat of extravasation are, loss of the power of swallowing, from paraly- 
sis of the glossopharyngeal, difficulty of protruding the tongue, from 
paralysis of the hypoglossal, and huskiness of the voice, tumultuous 

1 "Essai sur l'origine de plusieurs pairs de nerfs craniens. Th^se de Paris," 1853, 
p. 32. 




the left hemisphere ; 5, right half of pons ; c, 
right half of medulla oblongata ; d, right half of 
spinal cord ; e, right facial nerve ; /. fibre of 
origin from nucleus in medulla oblongata; g, 
descending fibre decussating at upper border 
of pons ; h, ascending fibre ; i, sensory root of 
spinal nerve; k y motor root of sensory nerve ; 
Z, lesion in pons; m, lesion in left hemisphere; 
n. paralyzed part supplied by facial; o, para- 
lyzed part supplied by spinal nerve. 



116 * DISEASES OF THE BRAIN. 

action of the heart, dyspnoea and gastric derangements, from paralysis 
of the pneumogastric nerve. There is in addition paralysis of one or 
both sides of the body. 

An extravasation into the cortical substance of the cerebrum is 
characterized by no very definite aggregation of symptoms. There 
may be delirium, coma, disorders of speech, convulsions, paralysis, 
contractions or rigidity of either the paralyzed or sound limbs, vomit- 
ing, derangement of respiration, and occasionally anaesthesia or hyper- 
sesthesia. Paralysis when present is upon the opposite side of the 
body from that of the lesion. 

When the extravasation is in the white substance of the cere- 
brum, not included in the direct motor and sensory tracts, there may 
be no marked symptoms of diagnostic value. I have known cases in 
which large foyers have been formed with no other symptoms than 
intense pain in the head and persistent vomiting. But when blood 
is extravasated into the white tissue the quantity is ordinarily great, 
and as a consequence there are often symptoms present which are 
due to resultant pressure upon other portions of the encephalic mass. 
Thus there may be coma, paralysis, loss of sensibility, stertorous res- 
piration, and other phenomena indicating derangement of the motor 
and sensory ganglia. The passage of the extravasated blood into the 
ventricles almost invariably causes contractions or convulsions of the 
muscles of the opposite side of the body. 

The researches I have made * relative to the functions of the cere- 
bellum would seem to show that its office is not materially different 
from that of the cerebrum. Still, I think there are some indications 
which, although not perhaps giving us the right to form a definite 
conclusion, are yet sufficiently well marked to enable us to arrive at a 
probable diagnosis between haamorrhagic lesion of the cerebrum and 
that of the cerebellum. Thus, vertigo is almost an invariable accom- 
paniment of the cerebellar extravasation ; vomiting is much more gen- 
erally met with than when the cerebrum is affected ; hemiplegia is not 
so common ; the sensibility is never disturbed ; and the pain is in the 
back of the head. 

Ferrier 2 has very clearly shown that irritation of the cerebellum 
produces nystagmus and defective power of ocular coordination. But 
I am not aware that these phenomena have been noticed in cases of 
cerebellar haemorrhage. Hillairet, 3 in his excellent memoir, does not 
mention them as features of the affection. He distinguishes two 

1 " The Physiology and Pathology of the Cerebellum." Quarterly Journal of Psycho- 
logical Medicine, April, 1869. 

2 " Experimental Researches in Cerebral Physiology and Pathology." " West Riding 
Lunatic Asylum Reports," vol. iii., 1873, p. 69, et seq. 

3 "Hemorrhagic cerebelleuse," Annuaire de medecine et chirurgie pratiques, 1859, p. 
39. Also Archives de medecine, 58., 



CEREBRAL HEMORRHAGE. 117 

forms of this lesion. In the one, the onset is sudden, and death soon 
follows ; in the other, the course of the affection is slow, and life may 
he prolonged for a considerable period. In this latter, vomiting is a 
prominent feature. Hemiplegia, according to him, is always crossed. 
Sensibility remains unaffected till near the close of the disease by 
death, and there are no convulsions. The speech is not often affected. 
The special senses he did not find notably deranged, except in the last 
stage. In this result he differs with several writers on the subject. 

Besides a number of cases, some of which are referred to in the 
memoirs cited, one has occurred in my experience, in which I had the 
opportunity of making a post-mortem examination. 1 

A man had suffered from vertigo, occasional convulsions, attacks 
of nausea, and vomiting, and a constant and violent pain affecting the 
back of the head. The symptoms had ensued in consequence of a se- 
vere blow which he had received on the back of the head, by raising 
himself too soon while the horse he was riding was passing under a 
low archway. 

When this man attempted to walk, he reeled and staggered as if he 
were drunk. The upper extremities and the organs of speech were 
not affected ; he had the entire control of his legs when lying down, 
and there was no diminution of sensibility anywhere. At last, he be- 
came paraplegic, and shortly afterward died in a convulsion. The 
post-mortem examination showed the existence of an abscess which 
had obliterated nearly the whole of the left lobe of the cerebellum. 
The other parts of the brain were, so far as could be perceived, per- 
fectly healthy. 

Besides the occurrence of local secondary lesions, the immediate re- 
sults of the presence of a foreign body in the cerebral tissue, there are 
others, which are due to the interruption of the normal brain-functions, 
which haemorrhage so generally induces. Thus, atrophy of the cere- 
bral structure may result, as has been pointed out by Cotard a and oth- 
ers, or the degeneration may extend to the spinal cord, as is so well 
shown by Bouchard. 8 In this latter event the process does not begin 
till about the end of the fourth or fifth month. It is mainly charac- 
terized by the supervention of permanent contraction of certain of the 
paralyzed muscles, and by exaggerated reflexes, and will be more 
appropriately considered under another head. 

Another point in connection with cerebral haemorrhage requires 
further elaboration. It is well known that the facial paralysis result- 
ing from ordinary cerebral haemorrhage is less extensive and less thor- 
oughly marked than when it is due to disease or injury of the trunk of 

1 Op. tit, p. 209. 

2 " Etude sur Patrophie partielle du cerveau," Paris, 1868. 

3 " Des degenerations secondares de la moelle epiniere," Archives gen. de medecine, 
1866. Also Hun's translation, American Journal of Insanity, 1869. 



118 DISEASES OF THE BRAIN. 

the seventh pair or to lesion of the pons Varolii. Thus we have seen 
that, in the former affection, the orbicularis palpebrarum escapes pa- 
ralysis, 1 and the other muscles supplied by the facial nerve are usually 
not so profoundly paralyzed as when the pons or the nerve is the seat 
of the disease. 

Many explanations have been offered of this remarkable circum- 
stance, but the one given by Landry 2 is more nearly reconcilable 
with the anatomy and physiology of the parts involved than any 
other. 

The nucleus of the facial is entirely comparable to the anterior 
cornua of the cord. It constitutes a little special motor nerve-centre 
which possesses a certain amount of autonomy. It is through this 
centre that the muscles of the face are directly made to contract. 
The encephalic fibres which connect it with the brain are only at the 
service of the psychical department, and an impulse sent through them 
is not of itself capable of exciting contraction in the muscles to which 
the facial is distributed. But, with the spinal cord, this nucleus pos- 
sesses reflex excitability, and, as is the case in diseases of the brain 
.in which the anterior columns suppress voluntary movements without 
destroying the reflex manifestations of which the gray substance of the 
cord is susceptible, so the cerebral lesion leaves to the nucleus of the 
facial the power to determine reflex contractions. It therefore con- 
tinues to be excited by sensitive excitations which reach it from the 
periphery. Thus, in facial hemiplegia of cerebral origin, we observe, 
from time to time, certain movements which appear to be voluntary 
because the provocative sensitive impression, which may only consist 
of the contact of air, remains unperceived. Accordingly, the orbicularis 
palpebrarum appears, above all the other muscles, to preserve its mo- 
bility, for its movements are principally excited by the stimulus of the 
light, which the lesion of the cerebral lobes does not prevent being 
reflected to the nucleus of the facial. In extensive diseases of the 
pons, however, the nucleus of the facial, situated as it is, in immediate 
proximity to this organ, is almost always compromised with it. In 
such a case, therefore, both reflex excitability and voluntary power are 
destroyed, and the paralysis is complete. 

Treatment.— The means of treatment in cerebral haemorrhage are, 
first, those which are applicable to the prodromatic stage, with a view 

1 Bazire, in his translation of Trousseau's " Clinical Lectures," calls attention to the 
fact that, in ordinary cases of cerebral haemorrhage, the patient, though able to close the 
eye of the affected side, cannot do so without, at the same time, closing the other, a fact 
which shows some loss of power. Since my notice was directed to this circumstance, I 
have observed that the patient is often sensible of the fact that the eye of the affected 
side cannot be closed as strongly or as rapidly as the other eye. 

2 Quoted by Poincare, " Lecons sur la physiologie normale et pathologique du systeme 
nerveux," tome deuxieme, Paris, 18*74, p. 55. 



CEREBRAL HAEMORRHAGE. 119 

of preventing any lesion ; second, those proper during the seizure ; 
and, third, those which are to be directed against the consequences of 
an attack. 

It often happens that an attack may be prevented, even where the 
threatenings are very decided. The condition of the brain is such that 
the indications are to lessen the tension of the blood as much as pos- 
sible. As I have already remarked, under the head of cerebral conges- 
tion, the bromides of potassium and sodium are peculiarly efficacious in 
accomplishing this end. Lately, in consequence of the investigations 
of Dr. S. Weir Mitchell, of Philadelphia, I have made much use of the 
bromide of lithium in cerebral congestion with or without a tendency 
to haemorrhage, and have reason to prefer it to either the potassium or 
sodium salt. One feature of its action, which renders it especially use- 
ful in such cases as those now under notice, is the short interval which 
elapses between its administration and the effect. I am very sure I 
have given it successfully in several cases in which the bromides men- 
tioned would not have acted so happily. In one of these, a gentleman 
from the South, who had already had an attack, and who was in con- 
sequence hemiplegic, was relieved of his vertigo, headache, numbness, 
and thickness of speech, by one dose of thirty grains, in less than half 
an hour. The bromide of calcium, a compound to which I have recent- 
ly called attention, 1 is still more eligible. It acts more rapidly than 
any of the other bromides, and may be given for a longer period with 
less derangement of the organism. The dose is from fifteen to thirty 
grains, or even more, if only a single dose is to be administered. The 
oxide of zinc may also be given with advantage. 

The bowels, if costive, should be opened by a brisk purgative ; the 
stomach, if overloaded, should be emptied by an emetic, during the 
action of which warm water should be freely drunk so as to obviate, 
as far as possible, all straining ; muscular exertion should be avoided, 
the head should be kept cool and well elevated, and the mind in a state 
of the utmost tranquillity. 

During an attack, and throughout the whole period of reparation of 
damages, the less that is done in the vast majority of cases the better. 
The question of the propriety of bloodletting will generally even yet 
arise, but should in nearly every case be decided in the negative. I say 
nearly, for I know of but one possible form of attack in which it can 
by any possibility not only not be useful, but fail to do harm ; and that 
is in a strong, plethoric person, with a full, bounding pulse, in whom, 
from the gradual development of the symptoms, we have reason to sus- 
pect that the haemorrhage is still going on. In such a case, six or eight 
ounces of blood may be taken from the arm. But, in the case of cere- 
bral haemorrhage, attended by coma and the ordinary symptoms of 

1 Note relative to Bromide of Calcium. New York Medical Journal, December, 18V1, 
p. 594. 



120 DISEASES OF THE BRAIN. 

the apoplectic condition, there is nothing to be done in the way of 
medication which can afford the slighest prospect of relief. It is true, 
a patient thus situated may recover if his attack is not of the severest 
kind, but it is not through any medicines we give him. Correct views 
relative to this point are far from being prevalent, and can only be es- 
tablished by regard being paid to the morbid anatomy and pathology 
of the subject. 

A clot in the brain is, to all intents and purposes, a foreign body, 
and both it and the walls of the cavity must undergo certain fixed and 
definite changes. In order that these changes may go on with the 
utmost possible regularity and certainty, all the powers of the system 
are requisite. The processes are not morbid ; on the contrary, they are 
in the highest degree conservative. To take blood from a body which 
is striving by all its agencies to repair an injury, is to deprive it of a 
portion of its strength without in the slightest degree accelerating the 
actions at the seat of the lesion. As Trousseau 1 remarks, no physician 
ever thinks of bleeding for an extravasation of blood under the skin, 
for he knows how perfectly absurd such a practice would be ; and yet, 
except as regards location, there is no difference between it and the 
cerebral clot. A prize-fighter, for instance, receives a blow in the face, 
which ruptures a blood-vessel and gives him a "black eye." He has an 
extravasation of blood into the cellular tissue. What would be thought 
of the physician who would recommend bloodletting from the arm, with 
a view of causing the absorption of the clot ? The prize-fighter has 
found out by experience that he can open the skin with a knife, and 
let the blood out. The practice is excellent, and would be admirable 
for the brain also, were this organ of no more vital importance than the 
skin of the face. I have never bled a patient for cerebral haemorrhage 
since 1849, and I am very sure that I have had no reason to regret the 
abandonment of the practice. 

It is a common practice for purgatives to be given, and even so 
conservative a practitioner as Dr. J. Hughlings Jackson 2 puts " two 
drops of croton-oil on the tongue," why, he does not state, and cer- 
tainly the practice is in direct antagonism not only with his assertion 
that " the chief thing is to keep the patient quiet," but with the gen- 
eral tenor of his theory of treatment. I have seen great annoyance 
and an aggravation of the symptoms from the indiscriminate admin- 
istration of croton-oil. It is only, in my opinion, admissible when 
there is obstinate constipation, and when after three or four days the 
bowels have not been moved. 

And then as regards iodide of potassium. There seems to be an 
idea prevalent that this substance exerts a powerful influence in caus- 

1 " Lectures on Clinical Medicine," Bazire's translation, Part I., p. 10. 

2 Reynolds's " System of Medicine," vol. ii., article " Apoplexy and Cerebral Haemor- 
rhage " p. 541. 



CEREBRAL HEMORRHAGE. 121 

ing the more rapid absorption of the extravasated blood, and hence it 
is frequently administered in large and frequently-repeated doses. I 
have often seen patients, at as early a period as possible, while still in 
a state of profound coma, dosed with the iodide of potassium to the 
extent of five grains every hour, with the object of causing the imme- 
diate absorption of the extravasated blood. That such a result is im- 
possible no one acquainted with the morbid anatomy and the pathology 
of the subject will deny. 

In fact, there is nothing to be done beyond keeping the patient per- 
fectly quiet, with the head well elevated, and in a room,* when possible, 
with a temperature of about 60° and thoroughly ventilated. Indica- 
tions should be met as they arise. The bowels, if not moved naturally 
every day, may be emptied by an enema of warm water ; the urine, if 
not passed by the patient, should be drawn off by the catheter ; the 
strength, if feeble, as indicated by the pulse, should be kept up by the 
cautious use of stimulants ; and, if the patient is restless and does not 
sleep well, some one of the bromides should be administered. 

Ergot may, on theoretical grounds, be recommended in those cases 
in which we have reason to believe that the haemorrhage is still going 
on ; but I have no personal experience of its power in such instances. 
If administered, it should be given with no sparing hand. 

The food should be of the most nutritious character, so as to be 
small in quantity, and should be taken frequently, day and night. 
Beef-tea, or the extract of beef, made according to Liebig's formula, 
supplies every indication. 

If symptoms of inflammation make their appearance, cold applica- 
tions may be made to the scalp, or a blister may be applied to the 
nape of the neck. Blisters or mustard-plasters to the wrist or ankles 
are absurd. 

Nothing should be done for the relief of the paralysis till all signs 
of irritation of the brain have disappeared, and the patient begins to 
feel the restraint of confinement, and to make efforts to move his par- 
alyzed limbs. These evidences of improvement generally begin soon 
after the eighth day. In about two weeks, therefore, it will be proper, 
in the majority of cases, to take active measures to restore the power 
of motion, and to prevent those contractions which tend to make a 
restoration much more difficult. The agents to be employed are pas- 
sive motion, strychnia, phosphorus, and electricity. The first is accom- 
plished by flexing and extending the joints of the affected limbs, by 
friction, and by kneading the muscles with the fingers. These move- 
ments should be performed every day for five or ten minutes at a time. 
The patient should likewise be encouraged to move the limbs by his 
own volition as often as possible short of causing fatigue. Strychnia 
should be given in doses of the one-twenty-fourth of a grain three 
times a day, or, preferably, by subcutaneous injection, in somewhat 



122 DISEASES OF TIIE BRAIN. 

smaller doses once a day. In old cases of hemiplegia, the effects of 
strychnia thus administered are often well marked, and are exhibited 
when administration by the stomach has failed to produce a beneficial 
result. This is seen in the following brief abstract of sixteen cases 
which will serve as types of numerous others which have occurred in 
my private practice : 

Case I. — H. A., aged fifty ; male ; right hemiplegia. Came under 
treatment January, 1865 ; strychnia ineffectual by the stomach ; thir- 
teen injections, of from one-thirty-second to one-twenty-fourth grain ; 
much improved. 

Case II. — J. S. ; forty-two ; male ; left hemiplegia. February, 
1865 ; thirteen injections ; much improved. 

Case III. — S. T. ; sixty ; female ; right hemiplegia. February, 
1865 ; strychnia ineffectual by the stomach ; nine injections ; much 
improved. 

Case IY. — I. S. ; sixty ; female ; right hemiplegia. April, 1865 ; 
five injections ; much improved. 

Case V. — M. T. ; fifty-two ; male ; right hemiplegia. April, 1865 ; 
strychnia ineffectual by the stomach ; eleven injections ; cured. 

Case VI. — O. S. ; sixty-three ; female ; left hemiplegia. April 30, 
1865 ; secondary contractions ; twenty-two injections ; no improve- 
ment. 

Case VII. — B. R. ; forty-seven"; male; left hemiplegia. June 11, 
1865 ; strychnia ineffectual by the stomach ; seven injections ; much 
improved. 

Case VIII. — R. F. ; fifty ; male ; left hemiplegia. June 17, 1865 ; 
strychnia ineffectual by the stomach ; eight injections ; cured. 

Case IX. — T. W. ; forty-eight ; male ; left hemiplegia. Septem- 
ber 5, 1865 ; eight injections ; much improved. 

Case X. — T. S. ; forty-nine ; male ; left hemiplegia. Septem- 
ber 7, 1865 ; secondary contractions ; five injections ; no improve- 
ment. 

Case XI.— J. J. ; fifty-seven ; male ; left hemiplegia. September 
11, 1865 ; secondary contractions ; no improvement. 

Case XII.— J. W. ; fifty-two ; male ; right hemiplegia, affecting 
arm only, at the time treatment was begun. September 27, 1865 ; 
strychnia ineffectual internally ; six injections ; cured. 

Case XIII.— W. M. ; forty-five ; male ; left hemiplegia. October 
19, 1865 ; strychnia ineffectual internally ; seven injections ; cured. 

Case XIV.— S. M. ; forty-one ; male ; right hemiplegia. June 
17, 1867 ; arm alone affected ; strychnia ineffectual by the stomach ; 
twenty injections ; cured. 

Case XV— M. C. ; forty-four ; male ; right hemiplegia, affecting 
tongue and face only. July 1, 1867 ; ten injections ; so much im- 
proved as to be able to talk with fluency. 



CEREBRAL HAEMORRHAGE. 123 

Case XVI.— C. C. ; fifty ; male ; right hemiplegia. May 4, 1869 ; 
strychnia ineffectual by the stomach ; thirty-five injections ; much im- 
proved. 

Dr. Charles Hunter 1 has called attention to the advantages to be 
derived from the hypodermic use of strychnia in hemiplegia ; and my 
former clinical assistant, Dr. R. A. Vance, 2 has adduced several cases 
to the same effect. Instances in support of the views above set forth 
occur daily in my private practice, and at the New York State Hos- 
pital for Diseases of the Nervous System. I have every reason, there- 
fore, to be convinced of the good results to be derived from the 
practice. 

Phosphorus administered in the form of phosphide of zinc, sepa- 
rately or in combination with the extract of nux-vomica, according to 
the formula given on page 68, is also a useful remedy. 

But no agent is so valuable in hemiplegia as electricity, and amend- 
ment almost invariably follows its use, even in old cases, in which 
there are tonic contractions. If the case is seen soon after the seizure, 
the induced current will generally be sufficient to produce contractions 
of the paralyzed muscles. The poles, terminated by wet sponges, should 
be applied to the skin covering the muscles, or in some cases to the 
nerves. The current should be strong enough to cause slight pain, or, 
if sensibility is lessened, to produce contraction. In old cases attended 
with atrophy of the muscles, and diminished or abolished electro-con- 
tractility, the primary current may be necessary. It should be applied 
in such a manner as to be interrupted, for contractions are only caused 
when the circuit is closed and opened. As the muscles improve in size 
and irritability, the induced current should be used. Care should be 
taken not to fatigue the patient, or to cause excessive pain by employ- 
ing a current of too great a degree of intensity. 

As regards the restoration of sensibility, it will generally be found 
to be less difficult than the removal of the motor paralysis. The anaes- 
thesia very often disappears or becomes much less spontaneously, and it 
does so from the centre to the periphery ; that is, if there be anaesthesia 
of the leg, the sensibility returns in the upper part first, and subse- 
quently in the lower part. The treatment consists mainly in the use of 
the electric wire-brush, which should be passed gently over the skin 
previously made dry. The other pole consists of a wet sponge. Either 
the induced or primary current may be used. If the latter, however, 
be employed, the wire-brush should constitute the positive pole. 

The recent advances in brain surgery give us reason to hope for 
success by operative procedure in those cases in which the clot involves 
the cortex or in cases of meningeal haemorrhage, the affection next to 

1 British and Foreign Medico- Chirurgical Review, April, 1868. 

2 Journal of Psychological Medicine, April, 1870. The first thirteen cases cited in 
this work w.ere published in Dr. 'Vance's paper. 



124 DISEASES OF THE BRAIN. 

be considered. When the symptoms clearly indicate the cortex as 
the seat of the extravasation it is an easy task to determine its exact 
location ; and if the situation is such that it can be reached by trephin- 
ing, the operation is entirely justifiable unless there are strong contra- 
indications. The question is, however, one which is to be settled for 
each individual case, and not to be determined abstractly. 



CHAPTER IV. 

CEREBRAL MENINGEAL HAEMORRHAGE. 

By the term cerebral meningeal haemorrhage is to be understood — 
1. An extravasation of blood between the cranium and the dura mater ; 
or, 2. An extravasation into the cavity of the arachnoid between the 
two layers of which this membrane is composed ; or, 3. An extravasa- 
tion into the sub-arachnoideal space between the arachnoid and the pia 
mater, or into the tissues of this latter membrane, or between it and the 
brain. There are thus — 1. Extra-meningeal haemorrhages ; 2. Intra- 
arachnoideal haemorrhages ; and, 3. Sub-arachnoideal haemorrhages. 
The first are almost always the result of traumatic cause, involving 
injuries of the cranium, by which the vessels of the dura mater are 
wounded. Extra-meningeal haemorrhage may likewise be produced 
by the operation of trephining, should any of the vessels of the dura 
mater be divided. It is, however, beyond doubt that this species may 
originate independently of wounds and injuries. 

The distinction between intra- and sub-arachnoideal haemorrhages 
was first pointed out by Prus, 1 to whom we are also indebted for much 
valuable information on the subject. Of one hundred and seventy- 
two cases collected by Gintrac, 2 five were extra-meningeal, one hun- 
dred and nine intra-arachnoideal, and thirty-four sub-arachnoideal. 

Symptoms. — The most prominent symptom of meningeal haemor- 
rhage is coma, which may appear suddenly, or be preceded by premon- 
itory symptoms, such as headache, vertigo, and general convulsions. 
The stupor is usually profound, and does not differ from that ob- 
served in the severe forms of cerebral haemorrhage. The power of 
motion is generally lost throughout the body, and consequently there 
is usually no hemiplegia. The reason for this is, that the haemorrhage 
is so extensive as to press upon both hemispheres. Reflex and auto- 
matic movements remain, except when the medulla oblongata is in- 
volved, when some of them are abolished. If the extravasation is in 
this latter situation, death soon takes place from cessation of respira- 

1 " Memoire sur les deux maladies connues sous le nom d'apoplexie meningee." Me- 
moires de Vacademie de medecine, tome xi., 1845, p. 18. 

2 Op. cit, tome i., p. 732. 



CEREBRAL MENINGEAL HEMORRHAGE. 125 

tory actions. Anaesthesia is present in the skin of those parts in which 
the power of motion is lost. 

In ordinary cases the patient may pass out of the comatose condi- 
tion from the fact of the brain becoming accustomed to the pressure, 
and he then may be able to speak, and to move his limbs, but his men- 
tal and physical faculties are greatly enfeebled, and a renewal of the 
haemorrhage again plunges him into a state of coma, from which he 
may again emerge. This sequence may be repeated several times, until 
death at last takes place. Before this termination there are vomiting, 
incontinence of urine and fasces, insensibility, and occasionally general 
convulsions. 

In a case reported by Dugast, 1 a woman entered the Hopital Neckar 
in a state of marked prostration. Her intelligence was not markedly 
impaired, but, though she understood almost every thing said to her, she 
answered only by monosyllables often unintelligible, and pronounced in 
a low voice. She was affected with paralysis of the left side of the 
face, and an incomplete paralysis both of motion and sensibility of 
the right side of the rest of the body. 

Four days afterward she was in a state of complete prostration, the 
paralysis was general. Up to this time the intelligence had remained 
almost intact. She died that day. The post-mortem examination 
showed the existence of a large sub-arachnoid extravasation at the 
base of the brain. On the inferior surface of the pons the blood had 
become consolidated into a clot which pressed upon the left lobe. On 
the right side of the pons the blood had not coagulated. This case is 
interesting as bearing upon the subject of cross-paralysis already con- 
sidered in the previous chapter. 

It has sometimes happened that meningeal haemorrhage, resulting 
from an injury of the cranium, has not caused any very prominent 
symptoms for a considerable period afterward. A teamster was struck 
on the head by a club in the hands of another man, was stunned for 
a few minutes, then recovered, and went about his business without 
complaining of his head. In about twelve hours afterward coma su- 
pervened, and he died without being aroused. A case is reported 
by Dr. Gibson, 2 in which a still longer period intervened. A man, 
sixty years of age, was found one morning, about eight o'clock, 
seated as if asleep at a desk, his arms crossed before him, and his 
head resting on them. It was discovered that he was profoundly in- 
sensible. He was sent to the hospital, where he lay comatose, breath- 
ing stertorously, and paralyzed on the whole of one side. At the end 
of two days he died. On post-mortem examination there was found 
fracture of the left side of the cranium, with rupture of the dura 

1 " Quelques considerations sur les hemorrhagies meningees cerebrates." These de 
Paris, 1869. 

2 Edinburgh Medical Journal, September, 1870, p. 199„ 



126 DISEASES OF THE BRAIN. 

mater and middle meningeal artery, from which latter, extensive 
haemorrhage had taken place. It was ascertained that, five days be- 
fore, he had fallen down a stone staircase, was stunned for a few 
minutes, but had soon recovered his senses. Doubtless during the 
whole of the intervening period the bleeding from the ruptured ves- 
sel had been going on. 

Prus, in the memoir cited, attempts to draw a symptomatological 
distinction between sub-arachnoideal and intra-arachnoideal haemor- 
rhage. Thus for him headache, dryness of the tongue, fever and de- 
lirium, are indications of intra-arachnoideal haemorrhage. Somnolence 
and coma are common to both forms, but, when they are conjoined 
with the phenomena mentioned, intra-arachnoideal haemorrhage is to 
be diagnosticated. But most authors doubt if the discrimination can 
in reality be made during life. Valleix ' declares that the difference 
is of greater anatomical than symptomatological importance, and 
Durand- Fardel 2 admits that it is difficult to present a characteristic 
view of the course and phenomena of sub-arachnoideal haemorrhage. 
I must confess that I see no greater anatomical reason for any differ- 
ence in the symptoms of the two forms of meningeal haemorrhage 
than there is for a difference between inflammation of the pia mater 
and inflammation of the arachnoid; Neither are there any char- 
acteristic symptoms which would serve to distinguish haemorrhage of 
the dura mater from either of the other forms. 

Causes. — Among the predisposing causes of meningeal haemor- 
rhage age occupies the first place. It is more frequently met with 
in young infants and in old persons than in those of middle age. 
Legendre, 3 in two hundred and forty-eight cases occurring in infants, 
and in which post-mortem examinations were made, found no instance 
of the child being over three years of age. Between one and two 
years would appear from his researches to be the period in which chil- 
dren are most liable to the supervention of meningeal haemorrhage. 

But Gintrac's 4 cases are of different import as regards this point, 
for of one hundred and sixty-five in which the age was noted, only 
ten were under ten years of age, while thirty-seven were between the 
ages of thirty and forty, sixty-seven were between fifty-one and eighty, 
and two of eighty-seven and eighty-eight years respectively. 

Meningeal haemorrhage is often produced by injuries of the skull, 
and results from sudden rupture of a healthy artery or vein. It may 
follow blows on the head, falls, or injuries with instruments which 
perforate the cranium, and may or may not be associated with fract- 
ures of the bones. 



l a 



Guide de medecine practicien," tome ii., Paris, 1866, p. 4. 

2 Op. cit, p. 173. 

3 "Recherches sur quelques maladies de Tenfance." Paris, 1846, p. 113 et 

4 Op. cit., p. 733. 



CEREBRAL MENINGEAL HEMORRHAGE. 127 

Extreme heat acting upon the head, venereal excesses, severe mus- 
cular efforts, excessive mental exertion, amenrrohoea, overfeeding, and 
constipation of the bowels, have been cited as exciting causes. The 
larger vessels, or the capillaries, may give way from being diseased, and 
consequently unable to resist the ordinary tension of the blood. Such 
a condition may be the result of the long-continued excessive use of 
alcoholic liquors, or may be due to hepatic disease. 

Prognosis. — The ordinary termination of meningeal haemorrhage is 
death. Of thirty-one cases in old persons, cited by Durand-Fardel, 
death occurred in twenty-six before the end of the fifth day, in one it 
took place on the seventh day, in two on the fifteenth, and in two in 
from twenty to twenty -five days. Legendre, in infants, ascertained the 
duration to be from eight to twelve days. Prus found death to ensue in 
cases of sub-arachnoideal haemorrhage before the end of the eighteenth 
day, but in instances of the intra-arachnoideal form life was sometimes 
prolonged for over a month. 

But recovery has. occasionally taken place through the formation of 
false membranes in such a manner as to circumscribe the extravasation, 
and thus to conduce to the absorption of its fluid portion, and Legendre 
has described a process occurring in children by which the sanguineous 
cyst is transformed into one containing serum, thus producing a species 
of hydiocephalus. Such terminations are, however, so very rare as to 
mitigate but to a very slight degree the gravity of the prognosis. 

Diagnosis. — The diagnosis of meningeal hasmorrhage is a matter of 
much difficulty. Still, there are certain characteristics which aid us 
somewhat in arriving at a correct opinion. Thus, from cerebral hasmor- 
rhage, it may usually be distinguished by the fact that the coma, when it 
exists, comes on gradually, that the headache is a much more prominent 
symptom, that there is not often hemiplegia — the paralysis amounting 
to a general resolution — and above all, by the remissions which so fre- 
quently mark its course. Durand-Fardel 1 declares that when the 
coma and general abolition of the faculties indicate the existence of 
strong cerebral pressure not accompanied by paralysis, properly so 
called, or only by incomplete paralysis, perhaps more strongly marked 
on one side than on the other, we may suspect the presence of menin- 
geal hasmorrhage ; that a cerebral hasmorrhage, or an acute softening 
sufficiently extensive to produce such pronounced symptoms of com- 
pression, is always accompanied by complete paralysis involving a 
lateral half of the body, and that the full development of the phe- 
nomena is ordinarily preceded by violent headache. 

From cerebral congestion the diagnosis must be occasionally al- 
most if not altogether impossible, and the same is true of cerebra 1 
softening. The remissions when present in meningeal hasmorrhage 
will afford important assistance in establishing the existence of the 

1 Op. cit., p. 168. 



128 DISEASES OF THE BRAIN. 

disease, but when they are absent the difficulties in the way of an ex- 
act discrimination may be insurmountable. 

Morbid Anatomy and Pathology. — An extravasation of blood be- 
tween the cranium and the dura mater, extra-meningeal haemorrhage, 
is, as nas already been said, almost invariably the result of traumatic 
cause. Gintrac, 1 however, with his usual industry, has collected five cases 
in which it appeared to be idiopathic. The first of these he quotes 
from Dr. J. H. Wythes, 2 of Port Carbon, Pennsylvania, but he omits to 
state that the child had been playing- on the door-step, and that a pain 
in its ankle was supposed by the parents to have been due to a sprain. 
It is probable, therefore, that the child fell and struck its head. The 
next morning it was found dead in bed. On post-mortem examination, 
an extravasation of blood, amounting to about half an ounce, was 
found between the skull and dura mater, on the upper surface. 

In the other cases the blood appears to have been effused during 
extreme congestion of the meningeal vessels, one or more of the latter 
having given way under the excessive tension to which they were sub- 
jected. In one quoted from Abercrombie, there were numerous clots 
scattered over the interior surface of the dura mater, and which seemed 
to have come from the Pacchionian bodies. These elevations were 
very vascular, being gorged with blood: 

The anatomical characteristics of intra- and sub-arachnoideal haem- 
orrhages have been very thoroughly given by Prus. 3 In the former 
the blood is extravasated by exhalation, that is, there is no visible 
rupture of blood-vessels, and, if life be prolonged to the fourth or fifth 
day, a false membrane is formed by which the clot is retained in appo- 
sition with either the parietal or visceral layer of the arachnoid. This 
membrane eventually becomes organized by the formation of vessels in 
it, and may, therefore, be the source of another haemorrhage; for, as 
Charcot and Yulpian * have shown, these vessels are numerous, large, 
possessed of very thin walls, and are, therefore, in a favorable condi- 
tion for giving way under the tension of the blood. 

Brudet 5 previous to Prus had described the false membranes 
which play so important a part in intra-meningeal haemorrhage, and 
had pointed out their resemblance to the arachnoid and their liability 
to be the source of other haemorrhages, and at about the period of 
Prus's publication Mr. Prescott Hewett 6 called attention to extrava- 
sations attached to the free surface of the arachnoid, and kept in 

1 Op. cit., tome i., p. 646. 

2 "Three Cases of Infantile Apoplexy." North American Medico- Chirurgical Re- 
view, January, 1858, p. 70. 

3 Op. et loc. tit. 

4 Gazette hebdomadaire, 1860, pp. 728, 789, 821. 

6 " Memoire sur l'hemorrhagie des meninges." Journal des connaissances medico- 
chirurgicales, 1839. 

Medico- Chirurgical Transactions, vol. xxviii., 1845. 



CEREBRAL MENINGEAL HEMORRHAGE. 129 

position by a false membrane not distinguishable by the naked eye 
from a true serous membrane. 

The clot may be extensive, covering nearly the whole surface of 
a hemisphere. The vessels which have given way, and have thus 
produced an intra-arachnoideal haemorrhage, are usually found in an 
atheromatous condition, and the vessels of the neo-membranes are 
especially liable to be thus diseased. 

Dr. Sutherland 1 in a very interesting memoir gives the details of 
ten cases of arachnoid cysts occurring in the insane: " On removing the 
skull-cap and dura mater, instead of the convolutions of the brain, with 
its vascular pia mater meeting the eye, there appears a reddish, pulpy, 
fluctuating swelling on the surface of the brain, having such a uniform 
appearance that the outline of the convolutions beneath it is invisible. 
On attempting to strip off the cyst from the surface of the brain it is 
usually found adhering to the visceral arachnoid along the centre of 
the longitudinal fissure ; it is easily separated from the convolutions 
on either side ; but if large enough to embrace the entire hemisphere 
is found again to be adherent below, but in this situation usually to the 
parietal layer of the arachnoid membrane." 

Of the ten cases reported by Dr. Sutherland, four were in ail proba- 
bility due to injury of the head. In five the mental aberration was 
organic dementia, in three general paralysis, and in two idiocy and im- 
becility. 

In sub-arachnoideal haemorrhages the blood is, as we have seen, ex- 
travasated into the space between the arachnoid and the pia mater, and 
is often entangled in the meshes of this latter membrane. As the 
blood when extravasated is mingled to a greater or less extent with the 
cerebro-spinal fluid, it often remains liquid. The quantity thrown out 
is frequently very large, amounting in some cases to apparently as 
much as sixteen or even twenty ounces. These figures must, however, 
be taken with some allowance for the amount of cerebro-spinal fluid 
with which the blood is combined. 

The anatomical relations are such as to admit of sub-arachnoideal 
haemorrhages being very extensively distributed throughout the cranio- 
vertebral cavity. In one case in which I made a post-mortem exam- 
ination, it occupied the whole base of the skull, and, in a case cited 
by Prus, the whole base of the cranium was filled with blood, all the 
ventricles were in the same condition, and even the sub-arachnoid 
cavity of the spinal cord was invaded. 

New membranes are never met with in this form of meningeal haem- 
orrhage. Atheroma of the arteries, especially of those at the base of 
the cranium, is the disease which is ordinarily the immediate cause cf 
the extravasation, and the torn vessel can generally be discovered with- 

1 "Arachnoid Cysts." "West Riding Lunatic Asylum Medical Reports," vol. i., 
1871, o. 218. 
10 



130 DISEASES OF THE BRAIN. 

out difficulty. Aneurisms of the basilar, the internal carotid, or other 
arteries of the base of the brain, have by their rupture been the cause 
of sub-arachnoideal haemorrhage. 

Treatment. — There is nothing to add under this head to the re- 
marks already made relative to the management of cases of cere- 
bral haemorrhage, except in those cases where the symptoms show 
that the clot is confined to a small area. In such instances tre- 
phining and the subsequent removal of the clot may be successfully 
accomplished. 

PACHYMENINGITIS AND HEMATOMA OF THE DUKA MATER. 

A peculiar form of meningeal haemorrhage, called haematoma, is 
met with under the dura mater. The blood is not diffused, but is 
collected in sacs which are formed of false membranes, the result of 
chronic inflammation of the dura mater ; or pachymeningitis as it 
has been designated by Virchow. These capsules are flattened 
ovals in shape, are three or four inches in diameter, and half an 
inch thick. They are usually situated at the vertex, and involve both 
hemispheres. When this is the case, the paralysis which results is 
bilateral. 

Symptoms. — The initial symptoms of haematoma of the dura mater 
are the results of chronic inflammation, and are slow in their progress. 
In many respects they resemble those indicative of softening, and con- 
sist of weakness of intellect, vertigo, a dull, circumscribed, persistent 
pain, and more or less tendency to stupor. The power of motion is 
generally diminished on both sides of the body, though occasionally 
there is hemiparesis. Paralysis is scarcely ever complete. Contrac- 
tions of the limbs and twitching of the muscles, especially of those of 
the face, have occasionally been observed. Gradually, through a pe- 
riod extending over several months, the stupor increases, and finally 
the patient becomes apoplectic. During the whole course of the dis- 
ease the pupils are strongly contracted. The patient dies comatose 
and frequently convulsed. 

Causes. — Early and old age are both predisposing causes, the dis- 
ease being met with mainly in children and very old persons. It is 
frequently seen in the insane, and may probably result from rheu- 
matism, the excessive use of alcoholic liquors, and fevers. The cause 
is sometimes to be found in wounds or injuries of the skull. 

Diagnosis. — It is doubtful if haematoma of the dura mater can be 
definitely recognized either in the stage of inflammation or that of haem- 
orrhage. Legendre 1 states that, in children, the most important diag- 
nostic mark is the permanent contraction of the hands and feet, which 
is so generally present ; but this symptom is certainly met with in other 

1 " Recherches sur quelques maladies de l'enfance," Paris, 1846. 



CEREBRAL MENINGEAL HEMORRHAGE. 131 

cerebral disorders, and may even result from reflex irritations. The 
diagnosis is rendered still more difficult by the fact that the disease 
under consideration is often associated with other cerebral disorders 
which mask or modify its symptoms. The absence of fever, the con- 
traction of the pupils, the slowness and irregularity of the pulse, the 
facts that there are no vomitings and no general convulsions, that the 
nerves distributed to the several parts of the face are not paralyzed, 
that there are constant and very severe headache and a gradually in- 
creasing tendency to stupor, are, according to Jaccoud, 1 sufficient to 
indicate the presence of hsematoma of the dura mater. I am of the 
opinion that they only enable us to give a guess which has some basis 
in probability, for I have several times witnessed exactly such a condi- 
tion as that described, and after death found other morbid conditions 
than hsematoma. 

Prognosis. — This is unfavorable, death resulting sooner or later, 
according to the extent of the disease and the natural powers of the 
patient. 

Morbid Anatomy and Pathology. — The first stage of hsematoma 
of the dura mater is characterized by the formation of the false 
membranes, to which allusion has already been made. These mem- 
branes are found on the internal surface of the dura mater, and are 
reticulated, presenting somewhat the appearance of spiders' webs. 
They generally have their seat near the sagittal suture, and extend 
to both hemispheres, being only separated from them by the arach- 
noid and pia mater. Virchow, who has studied their formation w T ith 
greater care than any other observer, has found more than twenty 
layers of them, one on top of the other, and traversed by numerous 
blood-vessels. 

Owing to this great vascularity, to the extreme tenuity of the ves- 
sels, and to the absence of any perivascular support, haemorrhage is 
liable to occur, and the several lamellae thus constitute a sac into wbich 
the blood may be poured. This, pressing upon the cerebrum below, 
and constantly being enlarged by subsequent haemorrhages, gives 
rise to the symptoms observed during life. The vessels may be more 
liable to rupture from the existence of atheromatous degeneration 
of their coats. 

Anatomically and pathologically hsematoma of the dura mater 
differs from intra- arachnoideal haemorrhage in the facts that the ex- 
travasation is between the dura mater and parietal layer of the arach- 
noid, and that the formation of the membrane precedes the hsemorrhage. 
Those authors who regard the arachnoid as consisting of but a single 
layer, and who consequently do not admit the existence of intra- 
arachnoideal hsemorrhage, must consequently concede that there are 
two kinds of extra-arachnoid eal hsemorrhage, one in which the mem- 
: "Traite de pathologie interne," tome i., Paris, 1870. 



132 DISEASES OF THE BRAIN. 

brane forms subsequently to the appearance of the extravasation, and 
the other in which the haemorrhage is the direct consequence of the 
formation of the membrane. 

Others again, as, for example, Gintrac and Durand-Fardel, evi- 
dently regard what they describe as intra-arachnoideal haemorrhage as 
identical with haematoma of the dura mater ; and it is quite certain 
that many of the cases adduced by Gintrac as examples of intra- 
arachnoideal haemorrhage are in reality instances of pachymeningitis 
with subsequent sanguineous extravasation. 

The difficulties in the way of a complete understanding of the 
subject are greatly lessened by remembering the distinction pointed 
out above, that haematoma of the dura mater is a secondary affec- 
tion, the direct result of inflammation and the formation of false 
membranes ; while in intra-arachnoideal haemorrhage the membrane 
is derived from the extravasated blood, which is the first step in the 
morbid process. 

The size of the cysts is subject to much variation, the quantity 
of blood ranging from one or two to sixteen or even more ounces. 
By the pressure which they exert upon the brain, the convolutions 
are flattened, and even softening of the cerebral tissue may be pro- 
duced. 

Treatment. — This requires no amplification at my hands, as I do 
not believe in the efficacy of any means for curing the affection. All 
that can be done is to palliate the more violent symptoms, such as 
the headache and feebleness of mind and body, by anodynes and 
stimulants, and of these, morphia administered hypodermically, and 
alcohol in some one or other of its numerous forms, are to be pre- 
ferred. Bloodletting and blistering are worse than useless. 



CHAPTER V. 

PARTIAL CEREBRAL ANJEMIA FROM OBLITERATION OF CEREBRAL BLOOD- 
VESSELS {ISCHEMIA). 

Obliteration of cerebral blood-vessels may take place— 

1. By thrombosis of the arteries. 

2. By embolism of the arteries. 

3. By thrombosis of the veins or sinuses. 

4. By embolism or thrombosis of the capillaries. 

I.— THROMBOSIS OF CEREBRAL ARTERIES. 

By cerebral arterial thrombosis is understood a condition in which 
an artery of the brain undergoes narrowing of its calibre by the depo- 



PARTIAL CEREBRAL ANEMIA, ETC. 133 

sition of fibrine from the blood on its internal surface. The clot thus 
formed is called a thrombus. 

Symptoms. — The phenomena observed in consequence of the forma- 
tion of a' thrombus in a cerebral artery are gradual in their develop- 
ment, and are often interrupted by stages of apparent improvement. 
Headache, as in so many other affections of the brain, is a promi- 
nent symptom and is almost constantly present. It is not usually 
diffused over the whole head, but occupies a place having a close rela- 
tion in situation with the seat of the disease. It is rarely of a very 
aggravated character, and is remarkable rather for its persistency 
than its severity. In several cases which have come under my notice, 
the pupil of the eye of the affected side was dilated from the first, 
and there were ptosis and strabismus, showing that the third nerve 
was involved. 

At a very early period in the progress of the disease it is not un- 
common to meet with marked difficulties in the faculty of speech, and 
these not only relate to the articulation, but to the memory of words. 
As regards the first-mentioned form, there may be restraint in the 
movements of the tongue, the lips, or both, or there may be a loss of 
coordinating power in the muscles concerned in speech without any 
actual paralysis. Special inconvenience is, therefore, experienced when 
attempts are made to pronounce words in which the labial and lingual 
letters are prominent. The gutturals in such cases are enunciated 
without difficulty. In the other form in which the memory of words is 
impaired, the patient is constantly at a loss for language with which to 
express his ideas; and, though the proper words may be supplied to 
him, he almost immediately forgets them again. The full considera- 
tion of this interesting subject will be found under the head of aphasia. 

Vertigo, though generally present, is not usually severe, at least in 
the early stages. 

The incipient symptoms of paralysis soon make their appearance 
in the majority of cases, and, though there is a gradual advance in the 
loss of power, there are periods of almost entire remission. Thus the 
leg, or the arm, or the face, may be the original seat of the paralysis, 
and eventually the whole of one side be involved. In a case of prob- 
able thrombosis in a gentleman now under my charge, the paralysis 
was at first limited to the muscles supplied by the ulnar nerve and 
those concerned in deglutition. For one period of five days after I 
first saw him, there was an entire remission of his symptoms, and he 
could move his hand and swallow as well as ever, but gradually the 
power was again lost, and other muscles became involved. At the 
present time he is almost entirely hemiplegia 

Sensibility is also generally abolished or impaired on the paralyzed 
side, and thus the various forms of numbness, such as tingling, formi- 
cation, etc., are present. 



134 DISEASES OF THE BRAIN. 

The mental symptoms are usually apparent from the first, but may 
be altogether absent or else so slightly shown as not to attract atten- 
tion. The memory is impaired, not only as regards words, to which 
reference has already been made, but also events and circumstances, 
especially those of recent date. The names of persons and things are 
likewise readily forgotten. In the case of a gentleman whom I saw in 
consultation, and in whom I diagnosticated thrombosis, there was left 
hemiplegia involving both arm and leg, but not the foot, which had 
begun in the fingers and gradually extended. There was no special 
difficulty of speech except as regarded the recollection of words, but 
the memory was wonderfully impaired in every other respect. I en- 
tered his room upon one occasion just as the servant was carrying out 
a tray with the remains of his breakfast. Not three minutes had 
elapsed since he had eaten, and yet he assured me he had tasted noth- 
ing since the day before. The loss of memory was the first symptom 
observed in this case. Soon afterward he began to improve, and he is 
now, after fifteen months, free from paralysis, and with his memory 
almost as good as ever. The loss of memory in such cases seems to be 
due in the main to the fact that the power of concentrating the atten- 
tion upon any subject is very much diminished. There is likewise an 
indisposition to exert the powers of the mind or body, and thus the 
patient tends to pass into a condition of apathy. Somnolence is a fre- 
quent symptom. 

An interesting case 1 of what was probably cerebral arterial throm- 
bosis was admitted to the New York State Hospital for Diseases of the 
Nervous System, August 22, 1870, and came under my observation. 
The patient, a man forty-one years of age, was temperate, and had 
never had either syphilis or rheumatism. In March, 1868, he was seized 
with a dull pain in the right knee, accompanied with numbness. There 
soon followed formications and pricking sensations, limited to the right 
foot. These gradually extended upward, and, at the end of two weeks, 
had reached the shoulder, when he became entirely hemiplegic. Dur- 
ing this attack his consciousness was not affected, and his organs of 
special sense, except his touch, were unimpaired. On the 11th of 
May following, the patient suddenly lost the power of speech, but ex- 
perienced no disturbance of consciousness. He remained completely 
aphasic for four months, being only able during this time to utter a few f 
sounds which could not be interpreted into intelligible words. He then 
began to enunciate a few words, and gradually acquired more facil- 
ity, though his power of coordination was far from perfect when he 
came to the hospital. His paralysis remained complete for nearly a 
year. 

When admitted there was hemiplegia of the right side of the body 

1 See the author's " Clinical Lectures on Diseases of the Nervous System." New Yorls. 
1874, p. 1. Case reported by Dr. T. M. B. Cross. 



PARTIAL CEREBRAL ANAEMIA, ETC. 135 

except the face; his eyesight, hearing, and other special senses, were 
unimpaired, and his intellect was clear. There was no loss of the mem- 
ory of words, and no impairment of the motor power of the tongue, but 
simply a defect in the faculty of coordination of the muscles used in 
articulation. There was more difficulty in pronouncing labials and Un- 
guals than gutturals. Tactile sensibility, electro-muscular sensibility, 
and contractility, together with the temperature, were markedly dimin- 
ished in the right arm, while sensibility to pain and deep pressure was 
normal. The bladder and rectum were not paralyzed. 

In talking, he had a peculiar hesitating, stammering manner, highly 
characteristic of his disease. There were certain words which he was 
totally unable to pronounce with any degree of accuracy, even after 
much effort — "Peter Piper " — words which begin with explosive labial 
letters, and others similarly constructed troubled him greatly. The 
ophthalmoscope showed the existence of atrophy of both of the disks, 
and of retinal anaemia. 

Under the use of strychnine hypodermically administered, phospho- 
rus, and the primary current to his brain and the faradaic to the para- 
lyzed parts, very marked improvement in all his symptoms was produced. 
He regained a considerable amount of power in the arm, became able 
to walk several miles at a time, and acquired the ability to articulate 
distinctly any words he wished to say. The sensibility returned, and 
the nutrition of the affected limbs was manifestly improved. 

In another case, also the subject of a clinical lecture, 1 there was 
probably thrombosis of the basilar artery. The patient, a woman, aged 
thirty-five, while at work wringing out clothes and exerting a good 
deal of force, experienced a sensation of numbness in the right arm and 
leg, which was attended with slight loss of power, though not enough to 
cause her to desist from her labor. At the time of the attack there 
were no head-symptoms of any kind, and she noticed no paralysis of 
the face. Her speech was not affected. At the time of her admission 
into the New York State Hospital for Diseases of the Nervous System, 
there was paralysis of motion and sensibility of the right arm and of 
motion on the left side of the face. 

The case was therefore one of cross-paralysis, and it was this fact 
which mainly induced me to locate the lesion in the pons Varolii. 

The speech was indistinct, but this was manifestly due to paraly- 
sis of the tongue and of the other muscles concerned in articulation. 

In the case in question there had been acute articular rheumatism, 
but the heart was free from functional or organic disease. The attack 
was not manifested with the suddenness which characterizes embolism, 
and there were no loss of the faculty of language, and no mental dis- 
turbance, which would probably have resulted had the middle cerebral 
artery been occluded. Besides, the face and the limbs would have 

1 Op. cit. t p. 130. 



136 DISEASES OF THE BRAIN. 

been paralyzed on the same side, all of which considerations induced 
me to believe that the case was one of thrombosis of a limited portion 
of the basilar artery. 

During the first stage of thrombosis, before the artery is entirely 
closed, amendment, and even complete recovery, may take place. The 
remissions in the symptoms already referred to are due to the establish- 
ment of the collateral circulation, and this may become so complete as 
to eventuate in cure. It must be confessed, however, that the condi- 
tion of anaemia to which the foregoing symptoms are due, in the great 
majority of cases ends in softening — a subject which will presently be 
considered as one of the consequences of thrombosis and other morbid 
states. 

Causes. — Thrombosis of an artery may result from atheroma or 
from endarteritis, by reason of which its elasticity is diminished and 
the smoothness of its lining membrane destroyed. Both these condi- 
tions retard the course of the blood, and favor the deposition of fibrine 
on the internal periphery. The walls of the vessels may be healthy, 
and a thrombus may then be formed through a weak action of the 
heart — the result of fatty degeneration or other cause impairing its 
strength. 

Certain conditions of the system, such as that which accompanies 
rheumatism, may induce thrombosis through the excessive amount of 
fibrine present in the blood and which renders this fluid more readily 
coagulable. It is probable, also, that other diseases and particular 
articles of food — as, for instance, alcohol, fat, and starch — when taken 
in excess, especially when conjoined with insufficient physical exercise, 
may so alter the composition of the blood — inducing hyperinosis — as to 
lead to a like result. Inordinate mental exertion, tending as it does to 
diminish the tone of the arteries by keeping them in a condition of over- 
distention, may likewise cause the formation of thrombi. 

It has apparently resulted from exposure to intense heat, from sup- 
pression of the menstrual flow, from severe emotional disturbance, and 
from blows on the head. 

It is much more common in males than in females, and in persons of 
advanced years than in the young. 

Pressure may be exerted upon a cerebral artery by a tumor or other 
extraneous body, and narrowing of its calibre and a consequent throm- 
bus be produced. Gintrac a cites a case of the kind. A young man 
had suffered for several days with headache and loss of power in the 
lower extremities. Coma supervened, but he was still able to answer 
questions. There was then pain in the back of the head, the pupils 
were dilated, the mouth was drawn to the right, the respiration was 
laborious but not stertorous, and the left side became completely 
paralyzed. He died on the fifth day. On post-mortem examination a 
1 Op. cit, tome i., p. 444. Quoted from Roupell, Medical- Times, 1844, vol. ix., p. 370. 



PARTIAL CEREBRAL ANEMIA, ETC. 137 

firm clot was found to occlude the right middle cerebral artery, and it 
extended to the internal carotid artery, but did not pass into the middle 
cerebral artery beyond th e point of obstruction. At this place in the 
fissure of Sylvius a small granulated mass, something like a Pacchi- 
onian gland, pressed upon the artery and closed it. In such a case the 
symptoms will of course be developed with much greater rapidity than 
when the cause of the occlusion resides in the artery itself. 

Diagnosis. — Arterial thrombosis is distinguished from cerebral con- 
gestion by the facts that the mental and other symptoms are more pro- 
found in character, and that the patient has generally passed the primo 
of life. The existence of paralysis among the early symptoms will 
likewise tend to the formation of a correct opinion. From cerebral 
haemorrhage it is diagnosticated by the circumstance of its gradual de- 
velopment; from encephalitis by the absence of fever and the more 
chronic nature of the disease ; and from embolism by its slow progress 
and the impossibility of denning the exact period of its beginning. 

Prognosis. — The prognosis in cerebral arterial thrombosis is unfa- 
vorable, for the reason that, although the morbid process may advance 
slowly, and may even be spontaneously arrested in its course before 
the artery is closed, the tendency to complete obliteration is always 
great, and the chance of sufficient circulation being carried on by the 
collateral vessels is very remote. The disposition to softening, there- 
fore, always exists, and generally cannot be overcome. The inade- 
quacy of any medical treatment to control the action going on within 
the artery, or to aid to any great extent in the development of the 
collateral circulation, is also an element in forming an opinion as to the 
ultimate result. 

Morbid Anatomy and Pathology. — Although Virchow " was the first 

to write distinctly in regard to the nature of thrombosis, the condition 
was recognized long before his researches were made, and cases of clots 
plugging up the vessels are to be found detailed by many of the older 
medical authors, among whom Abercrombie, Carswell, and Cruveilhier, 
may be mentioned. Since Virchow began his observations in this direc- 
tion, many instances have been recorded and a large number of memoirs 
have been issued upon the subject. An interesting case was related by 
Dr. Packard, 2 of Philadelphia, at a meeting of the Pathological Society 
of that city held in December, 1859. The patient, who had been under 
the care of Dr. Heller, was a bachelor, fifty-one years of age. At six 
o'clock in the morning, at the beginning of February, he was seized with 
paralysis of the left arm and leg. He was a man of very regular habits, 
and of fanatical love for every thing instructive, and an accomplished 
scholar in botany, geography, and languages. The paralysis was soon 
relieved, and he was able, four weeks afterward, to go out again and to 

1 Froriep's Neue Notizen, 1846, Heft xxxvii. 

2 North American Medico- Chirurgical Review, vol. iv., 1860, p. 306. 



138 DISEASES OF THE BRAIN. 

use his arm tolerably well. About the middle of March, in consequence 
of a fatiguing walk the previous evening, and an attack of diarrhoea 
during the night, complete paralysis returned. From this he never re- 
covered, but yet did not die till the December following. Previous to 
this termination he had confusion of ideas and delirium. Upon post- 
mortem examination, among other morbid changes, a cavity in the right 
corpus striatum was found, and this was surrounded by a spot of soft- 
ening of the cerebral substance as large as an egg. The basilar artery 
was completely blocked up with clots, as was also the right carotid. 
These vessels were atheromatous, and the basilar artery was aneuris- 
mally dilated. The clots had all the appearance of being old. 

Dr. Dickinson * has brought forward five cases of occlusion of arte- 
ries, several of which I am disposed to think were of embolism, instead 
of thrombosis, as he considers them to be. Dr. Dickinson nowhere 
alludes to Virchow's investigations, but gives the whole credit of the 
discovery of the relation between emboli and the formation of concre- 
tions in the heart to Dr. Kirkes. The conclusions which he draws from 
his cases are by no means original, although he evidently so regards 
them. 

The questions to be considered in connection with the morbid 
anatomy of arterial thrombosis relate to the condition of the artery, the 
nature of the clot, and the changes which take place in those parts of 
the brain which are deprived of their due supply of blood. 

The affections of the artery, being similar to those which render it 
liable to rupture, need not be dwelt upon at any length here, as they 
have already been noticed under the head of the morbid anatomy of 
cerebral haemorrhage. Suffice it, therefore, to say that endarteritis and 
atheromatous degeneration are the diseased states generally met with. 

The calibre of the diseased vessel is diminished and the blood is 
therefore primarily obstructed in its course even before the beginning of 
the formation of a clot. In addition the internal coat of the artery is 
roughened, and hence the fibrine of the blood is readily caught and de- 
posited on the internal periphery. Little by little the layer becomes 
thicker from fresh accretions, until finally the vessel is entirely occluded. 

The clot which closes the vessel is, in the beginning, coagulated blood, 
and hence consists of fibrine and white and red blood-corpuscles. It 
adheres to the arterial wall and may be of a brown, yellow, gray, or 
white color. The consistence is greater at the base than at the pe- 
riphery, and it may contain granules of calcareous matter composed 
mainly of phosphate of lime. 2 The elements, with the exception of the 
fibrine, are gradually disintegrated and washed away by the current of 

1 " On the Formation of Coagulse in the Cerebral Arteries." St. George's Hospital Re- 
ports, vol. L, 1866, p. 257. 

2 Lancereaux, " De la thrombose et de l'embolie cerebrales. These de Paris," 1862, 
p. 86. 



PARTIAL CEREBRAL ANEMIA, ETC, 139 

blood \Thich continues to flow through the vessel before it is entirely- 
closed, and therefore the layers nearest the arterial wall consist almost 
entirely of fibrine, and the one nearest the centre of the vessel, which is 
the latest formed, of fibrine and corpuscles. An examination of such a 
clot with the microscope shows that the above-mentioned morphological 
elements are found in its centre, more or less changed, however, accord- 
ing to the age of the formation. A thrombus may undergo purulent 
softening and disintegration to such an extent as to result in its break- 
ing up into fragments, which may lodge in the vessel or its branches 
farther on, and thus constitute emboli. 

The region of the brain to which the artery undergoing occlusion is 
distributed is, of course, deprived to some extent of its blood, and hence 
presents at first an appearance of anaemia. And this is not prevented 
by the increase of the collateral circulation, which is never sufficiently 
vigorous to compensate entirely for the loss by the primary vessel. 

Microscopic examination shows the capillaries to be smaller and less 
numerous than in the normal condition, though there is not any palpa- 
ble softening. 

But after the artery is entirely closed a change ensues. The anaemic 
portion of the brain becomes red or pink, and this color is deepest on 
the borders, owing to the collateral circulation which is now fully es- 
tablished. This stage has been called red softening, but I am disposed 
to think the designation erroneous, and that it is liable to convey false 
ideas of the pathology. For it is perfectly possible at this time for the 
anaemic portion of the brain to be restored through the activity of the 
collateral circulation, with the effect of causing a cessation of the symp- 
toms. If, however, this should be insufficient to provide for the due 
nutrition of the affected region, softening takes place, and a cure be- 
comes almost impossible. 

Obliteration of a cerebral artery by thrombus does not always pro- 
duce notable symptoms. For these to follow, the morbid process must 
be set up in a vessel with but few and small collateral branches. Thus, 
if the internal carotid be obstructed, the circulation is carried on through 
the circle of Willis by the supply of blood derived from the vertebrals. 
The basilar artery might also be occluded at any limited region between 
a pair of transverse arteries, and the circulation still kept up by the 
carotids on the one side, and the vertebrals on the other. But any 
closure so as to involve one or more of the transverse arteries must lead 
to anaemia, and subsequent softening of the pons Varolii. Thus, in a 
case reported by Bennett, 1 in which there had been vertigo and other 
head-symptoms for several years, and in which paralysis of the left arm, 
without loss of consciousness, had suddenly supervened, the basilar 
artery was found entirely obliterated throughout its entire extent, all 

1 " Clinical Lectures on the Principles and Practice of Medicine," third edition, Edin- 
burgh, 1850, p. 370. 



140 



DISEASES OF THE BRAIN. 



the transverse arteries were of course closed, and the supply of blood to 
the pons was cut off on both sides of the mesial line. 

A somewhat similar case has recently been reported to me by a 
physician of this city. The, patient had suffered with paresis of all the 
limbs, with pain in the back of the head, occasional vertigo, irregu- 
larity of the respiration and circulation, and double facial paralysis for 
several months. He died suddenly while sitting quietly in his chair. 
On post-mortem examination the basilar artery was found occluded. 

Fig. 13. 




a, artery of the corpus callosum (anterior cerebral, right) ; d. middle cerebral artery ; c. posterior cerebral 
artery; d, superior cerebellar artery; e, anterior inferior cerebellar artery; f,. posterior inferior cere- 
bellar artery; g, obliteration of artery of corpus callosum (anterior cerebral, right); A, obliteration of 
middle cerebral artery; i, obliteration of basilar artery; k, obliteration of vertebral artery (left). 



and distended by a thrombus which reached from the point of union of 
the vertebrals to the posterior cerebral arteries, into the left one of 
which it extended two or three lines. 

A very interesting memoir by Hayem 1 alleges occlusion of the 
basilar artery by thrombus to be a cause of sudden death. In all his 
cases, four in number, the artery was closed throughout a great part of 

1 " Sur la thrombose par arterite du tronc basilaire, comme cause du niort rapide." 
Archives de Physiologie Normale et Pathologique, 1868, p. 270. 



PARTIAL CEREBRAL ANJ3MIA, ETC. 141 

its extent, as the result of extensive arteritis and the formation of dense 
clots. In the fourth case there was also thrombosis of the left middle 
cerebral artery, with difficulty of speech. 

The cerebral vessels most liable to be closed by thrombosis are the 
internal carotid, the middle cerebral, the basilar and the vertebral ; after 
these come the anterior cerebral, the posterior communicating, and the 
posterior cerebral. It is by no means rare to find two or more arteries 
simultaneously affected, and in one case cited by Gintrac ' the whole 
circle of Willis was obstructed, and, in a remarkably interesting case 
described by Heubner, 3 the right anterior cerebral artery, the left 
middle cerebral, the basilar, and the left vertebral were obliterated 
by thrombosis of syphilitic origin (Fig. 13). The arrows in the figure 
represent the course which the blood took by reason of the several ob- 
structions to its circulation. 

The vessels the closure of which produces the greatest disturbance 
of function are the anterior, middle, and posterior cerebral, which supply 
the hemispheres, the corpus striatum, optic thalamus, and other impor- 
tant ganglia. Besides the effect due directly to the anaemia, more or 
less disturbance results from the congestion posterior to the clot, and 
the consequent effusion of serum. 

Treatment. — A knowledge of the morbid anatomy and pathology of 
cerebral arterial thrombosis must satisfy us of the insufficiency of any 
medical treatment to cause the absorption of the clot obliterating the 
channel of the artery. Yet I have several times heard it gravely pro- 
posed to administer the iodide of potassium, with the view of accom- 
plishing this object. As regards facilitating the establishment of the 
collateral circulation, Nature will generally take care of this, and may 
even so far overdo it as to cause haemorrhage from the rupture of ves- 
sels not accustomed to the increased tension of the blood. It may 
therefore be necessary, in this latter condition of excessive action, to 
give the bromide of potassium in large doses. Should the circulation 
be feeble, the skin cold, and the patient disposed to somnolence, we 
have reason to suppose that the collateral circulation is not being formed 
with sufficient rapidity, and therefore the patient should be kept with 
the head low, brandy or other spirituous liquors administered, and the 
body wrapped up in warm blankets. 

For some time after the successful establishment of the collateral cir- 
culation there is more or less feebleness of mind and body. For this 
condition strychnia and phosphorus are especially applicable, and may 
be administered according to the formulas recommended under the 
heads of cerebral congestion and cerebral haemorrhage. Electricity is 
almost always useful. 

1 Op. cit, p. 443. 

8 "Die Luetische Erkrankung der Hirnarterien," Leipzig, 1874, pp. 87, 194. 



142 DISEASES OF THE BRAIN. 

II. EMBOLISM OF CEREBRAL ARTERIES. 

Embolism is the term applied by Virchow to the closure of an ar- 
tery by an embolus, which is a clot formed in some other part of the body 
and transported by the current of the blood to the vessel which it oc- 
cludes. It therefore differs from thrombosis in the facts that it is not 
associated with previous disease of the artery, and that the closure of 
the vessel is sudden. 

Symptoms. — In cerebral embolism there are no premonitory symp- 
toms. As in cerebral haemorrhage, the patient may be sitting per- 
fectly quiet when he suddenly loses consciousness and falls to the 
ground, comatose. As the stupor passes off, he finds that he is par- 
alyzed upon the side of the body opposite to the seat of the lesion. 

Or there may be no coma, but merely slight confusion of ideas for 
a moment or two with sudden accession of paralysis on a limited por- 
tion of one side, involving only the arm or leg. Or, again, the face or 
the tongue may be the only part paralyzed. Or there may be no 
paralysis anywhere, and no mental symptoms except as regards the 
faculty of language, which is entirely or partially lost. 

Sometimes there are ocular troubles, such as ptosis, strabismus, or 
blindness. 

Experience shows that the embolus, for reasons which will be given 
hereafter, generally lodges in the left middle cerebral artery, and that 
with the right hemiplegia — if there be paralysis at all — there is often 
aberration of the faculty of speech. 

The symptoms of mental derangement, with the exception of the coma 
of severe attacks, are not ordinarily prominent. I have, however, 
witnessed several cases in which they formed a very striking feature of 
the case. In one of these, in which the clinical history of the patient 
disclosed the preexistence of several attacks of acute articular rheu- 
matism, with subsequent endocarditis and mitral and aortic valvular 
lesions, there were hallucinations and delusions in addition to the 
complete paralysis of the left side. All these phenomena entirely dis- 
appeared within thirty-six hours. This case is one of the few in my 
experience in which the embolus had occluded an artery on the right 
side of the brain. 

In another, likewise with valvular disease of the left side of the 
heart, there was delirium from the first, and this disappeared as the 
collateral circulation was established. 

Erlenmeyer has written very excellently of cerebral embolism, but 
is, I think, incorrect in some points of his symptomatology. He states 
the ordinary phenomena of an attack to be as follows: 

There are no prodromata; sudden loss of consciousness, with pa- 
ralysis of several parts of the body. The facial, the hypoglossal, and 
the nerves of the extremities, are always more or less affected. Sensi- 



PARTIAL CEREBRAL ANAEMIA, ETC. 143 

bility is abolished in the conjunctiva, but is retained in the cornea. 
The pupils remain sensitive, and are neither contracted nor dilated, 
neither are there symptoms of concussion or compression. There are 
no vomitings and no contractions. The pulse is weak and small, and 
the temperature rather below the normal standard. Occasionally there 
are epileptiform convulsions. Psychical troubles do not ordinarily ap- 
pear till the collateral circulation becomes active, and local hyperemia 
is thus induced. 

The principal exception I have to make to the foregoing sequence 
of symptoms is the too absolute assertion of the paralysis of the 
facial, hypoglossal, and other nerves. I have seen several cases in 
which there was no paralysis to be detected in any part of the body 
by the most careful examination, and several others are on record. 
In one very interesting instance, occurring in a lady who had had 
repeated attacks of acute rheumatism, and who had at the time 
marked aortic insufficiency, headache and vertigo suddenly occurred 
while she was conversing with a friend, and her speech was cut short 
with as much suddenness as though she had been shot. There was 
no paralysis of the tongue, but all idea of language was abolished. 
In another, that of a gentleman with a similar clinical history, head- 
ache, vertigo, confusion of ideas, and amnesic aphasia, suddenly super- 
vened. That both these were cases of embolism can scarcely, I think, 
be doubted. 

And then, as regards the state of the pupils, my experience does 
not coincide with that of Erlenmeyer, for I have frequently found either 
dilatation or contraction of both pupils, or dilatation of one and con- 
traction of the other. 

In examining a case of recent embolism, the ophthalmoscope should 
always be used to view the fundus of the eye, and even in old cases 
valuable signs will often be obtained. The middle cerebral artery, the 
ordinary seat of embolus, arises from the internal carotid, after the an- 
terior cerebral and ophthalmic have been given off. Occlusion of its 
channel must, of course, throw an increased amount of blood into these 
last-named arteries, and, as the arteria centralis retinas is derived from 
the ophthalmic, it and its branches become enlarged. The ophthal- 
moscope will enable us to discover the congestion thus produced, and will 
often be the means of helping us to determine, in the absence of pa- 
ralysis, which side of the brain is the seat of the lesion. In older cases 
we will frequently find retinal congestion. 

The following case I quote not only as being the first of which I 
have any knowledge in which the ophthalmoscope was used in a case 
of cerebral embolism, but as being interesting from the fact that the 
embolus was on the right side. It is reported as 

Cerebral Embolism following Valvular Disease of the Heart. — John 
Turnbull, aged seventeen, was admitted into the Hull General Infirm- 



144 DISEASES OF THE BRAIN. 

ary, on April 25, 1867. He was tall, much wasted, and had a suffering 
expression, and converging strabismus of the left eye, the mouth being 
drawn very slightly toward the left side. Pulse 70, very thrilling in 
character, and a large coarse systolic murmur near the left nipple. He 
was perfectly sensible, complained of severe frontal headache, with 
confusion of vision, and stated that he had been in much the same con- 
dition for seven weeks, his illness beginning spontaneously with head- 
ache and vomiting, unaccompanied by loss of consciousness or con- 
vulsions. He had had an attack of acute rheumatism in the previous 
summer. He was ordered gr. iij of blue-pill and gr. ij of extract of 
henbane in a pill, and a draught of acetate of ammonia, three times a 
day, and spirit-lotion to the head. " No marked alteration in his con- 
dition, except progressive debility, took place till May 2d, when he 
complained of increased headache and dimness of vision, and, being un- 
able to expectorate, from excessive weakness, death from bronchial 
obstruction threatened. With the aid of some champagne, he rallied 
in about twenty-four hours, and at the end of a week was much im 
proved, having a clean tongue and good appetite, but the headache, stra 
bismus, and deviation of the tongue to the left, remained. On May 16th 
it was noticed that these symptoms had passed off, with the exception 
of the last mentioned. He was ordered a mineral-acid mixture. 

" A week later, as he still complained of some dimness of sight, he 
was examined with the ophthalmoscope. The retinal vessels were 
found much enlarged, and the veins very tortuous; the optic nerve- 
entrance of an intense red color, not being distinguishable from the 
surrounding parts except by the entrance of the vessels, the redness 
being chiefly due to a number of very fine vessels radiating from the 
centre. There was no morbid effusion in any part. He could spell 
easily from No. 15 of Jaeger's test-types (being unable to read and 
write). He was again examined at the end of another week, when the 
optic nerve-entrance was observed to be paler in color, so that its cir- 
cumference could be distinguished, but still much injected, and the 
vessels nearly as large and tortuous as before; sight was apparently 
perfect. He was discharged convalescent. 

" The peculiar form of paralysis in this case denoted some morbid 
condition within the cranium, which appeared to have its most easy 
and natural explanation in cerebral embolism, an opinion further sup- 
ported by the perfect recovery of the patient. The case received much 
additional interest from the information afforded by the ophthalmo- 
scope, for one may fairly believe that the intense congestion of the 
retinas denoted a similar condition of the brain, perhaps a state of re- 
action after the circulation had been reestablished through collateral 
channels." l 

1 British Medical Journal, IBS'?; also Quarterly Journal of Psychological Medicine, 
January, 1868, p. 178. 



PARTIAL CEREBRAL ANAEMIA, ETC. 145 

Causes. — The most common first step in the causation of cerebral 
embolism is acute articular rheumatism, which, by inducing acute en- 
docarditis, leads to the formation of emboli on the valves of the heart 
and other parts of the endocardium. Aneurisms of the aorta or other 
large artery, resulting in the coagulation of the blood in the aneurismal 
sacs, may likewise induce it, by a portion of the clot being washed off 
by the current. Esmarch 1 details a case in which, while an examina- 
tion was being made of an aneurism of the carotid, the patient sud- 
denly fell back in an apoplectic stupor. The whole right side was at 
once paralyzed, the facial muscles on the left side were convulsed, and 
four days afterward death ensued. Post-mortem examination showed 
that the left internal carotid, the middle cerebral, and the ophthalmic, 
were completely closed by coagula, which were identical in structure 
and appearance with the clot in the aneurismal sac. 

Emboli may also originate in the lungs, and, entering the left 
auricle through the pulmonary veins, finally lodge in a cerebral artery. 

Age appears to exercise no influence over the formation of emboli, 
but men are much more commonly the subjects than women, for the rea- 
son, undoubtedly, that they are more liable to attacks of rheumatism. 

Of sixty-two cases under my care, either alone or in consultation, 
in which I had reason to diagnosticate cerebral embolism, there was 
organic disease of the heart in all but four. Three of the cases were 
over sixty years of age; seven between fifty and sixty; eleven between 
forty and fifty; twenty-nine between thirty and forty; and twelve under 
thirty. Thirty-nine were males and twenty-three were females. 

Diagnosis. — From cerebral haemorrhage, embolism may be distin- 
guished by the following signs. It occurs without relation to age, 
while haemorrhage is much more frequent in persons over forty; there 
are no prodromata; the resultant paralysis is generally on the right 
side, while in haemorrhage there is no such predisposition; and it is in 
the great majority of cases associated with organic disease of the left 
side of the heart. Care, however, must be taken not to over-estimate 
the value of this diagnostic mark, valuable as it is. In one case under 
my charge, in which the symptoms pointed strongly to the existence 
of a cerebral embolus, and in which, after death, the left middle cerebral 
artery was found occluded, the heart was perfectly healthy; and in one 
other, in which cerebral embolus was diagnosticated, and in which there 
was mitral regurgitation, extravasation into the corpus striatum was 
discovered to be the cause of death. A case has recently been re- 
ported by Dr. J. Hughlings Jackson, 2 in which there was cerebral haem- 
orrhage with hemiplegia, together with extensive valvular disease of 
the heart. 

A patient now in the New York State Hospital for Diseases of the 

1 Archivfur Pathologie, Anatomie und Physiologie, B. xi., Heft 5, 1857. 
8 British Medical Journal^ October 29, 1870, p. 459. 
11 



146 DISEASES OF THE BRAIN. 

Nervous System has left hemiplegia, involving face, arm, and leg. It 
has already lasted seven months, although greatly improved. The 
hand and arm are much contracted. The attack was apparently in- 
duced by strong muscular exertion being made while in a stooping and 
constrained position. Most physicians will be disposed to agree with 
my diagnosis, that the case is one of cerebral haemorrhage, for the 
obvious cause of the paroxysm, the lesion being on the right side of the 
brain, the steady improvement and the muscular contractions, all point 
to extravasation of blood instead of embolus. Yet he is under twenty 
years of age, and, before the seizure, had an attack of acute rheumatism, 
with heart-symptoms. He now has aortic and mitral regurgitation. 
Such cases as the above are very instructive, and they show us how 
necessary it is to weigh all the facts, and how great is the possibility 
of making a mistake after all. For, although I am inclined to the view 
of haemorrhage, no definite opinion can.be given without a post-mor- 
tem examination. 

Still in a case of partial or complete hemiplegia, with or without 
apoplexy, in which the patient was below the age of forty, with the 
hemiplegia involving the right side, no muscular contractions and or- 
ganic disease of the left side of the heart, with or without previous 
attacks of acute articular rheumatism, cerebral embolus may safely be 
said to be the cause of the symptoms. Moreover, the paralysis from 
embolism, if it does not disappear within seventy-two hours after the 
seizure, does not gradually fade away as it so frequently does to a great 
extent in haemorrhage. 

It is a somewhat remarkable fact that in cerebral embolism the pa- 
ralysis may be very extensive and complete without the occurrence of 
other notable symptoms. Thus in the case of a young lady whom I saw 
in consultation with Drs. Polk and M. A. Wilson, there had been in 
childhood a severe attack of inflammatory rheumatism and several minor 
attacks subsequently. On the last day of September, 1874, she sud- 
denly became hemiplegic on the left side, but did not lose consciousness. 
There was no aphasia, pain in the head, convulsive movements, nor 
mental disturbance. The paralysis, however, involved the left arm and 
leg, and was exceedingly profound. The face was affected for a short 
time, but the tongue retained its motor power. Three months after- 
ward she could stand and walk a little, but was not able to raise the 
foot from the ground; the arm was absolutely immovablo. Here the 
clinical history, accompanied as it was with a record of heart-disturb- 
ance for several years, was such as to leave no doubt as to the lesion 
being embolism of an artery — probably the middle cerebral — of the 
right side of the brain. 

The suddenness with which embolism takes place, to say nothing of 
the other points in the clinical history, will suffice for the discrimination 
from thrombosis. 



PARTIAL CEREBRAL ANAEMIA, ETC. 147 

Prognosis. — The prognosis in cerebral embolism is grave, for the 
reason that the tendency to softening of the ansemic cerebral tissue 
always exists. But, if the patient passes over the first four or five days 
without any aggravation of his symptoms, and especially if they be 
mitigated in violence, there is considerable hope of a favorable result. 
Still, a guarded opinion should always be given till all head-symptoms 
have disappeared. 

Morbid Anatomy and Pathology. — The first rational explanation of 
embolism was made by Virchow, 1 in 1847, who, in his paper on acute 
inflammation of the arteries, distinctly explained the manner in which 
the vessels were occluded by clots transported in the blood from dis- 
tant parts of the body, and who associated these coagula with valvular 
disease of the heart. In two of the cases cited by him in which arteries 
were found closed by such clots, the valves of the heart were discovered 
to have others still attached to them, and exhibited traces of the sep- 
aration of those which were found in the vessels. 

Subsequently (in 1852), Dr. Senhouse Kirkes a called special atten- 
tion to the plugging up of the middle cerebral artery as a cause of soft- 
ening of the brain. Three cases, in which death followed, are adduced, 
in each of which the condition of non-inflammatory softening was found 
to exist in the brain. Dr. Kirkes's observations appear to have been 
made without any knowledge of Virchow's prior researches. He states 
that the paralysis met with in young persons may be due to the inter- 
ruption of a due supply of nutriment to the brain by the occlusion of 
an artery by a plug derived from the left side of the heart. 

Schiitzenberger, 8 among others, has written with great fullness on 
this subject. Among other conclusions not specially applicable to the 
particular point now under consideration, he states that fibrinous con- 
cretions may form in the heart or large vessels, may subsequently be 
detached and carried by the blood to the cerebral arteries, where they 
produce symptoms not essentially different from those noticed in cere- 
bral haemorrhage or acute softening. 

The only material points of difference under this head between 
thrombosis and embolism are, the suddenness of the attack, the part of 
the brain most liable to be affected, the origin of the clot, and the state 
of the blood-vessel which is obliterated. 

Relative to the first, the abrupt closure of a vessel as in embolism 
will, of course, produce more violent symptoms than if the occlusion 

1 " Ueber die akute Entziindung der Arterien." Archiv fur Pathol. Anatomie, B. i., 
1847, p. 272. In a paper on "Occlusion of the Pulmonary Artery," published in Froriep's 
Neue Notizen in 1846, he enunciated a similar theory. 

2 " On some of the Principal Effects resulting from the Detachment of Fibrinous 
Deposits from the Interior of the Heart, and their Mixture with tie Circulating Fluid." 
Medico- Chirurgical Transactions, voL xxxv., 1852. 

3 Gazette des Hopitauz, No. 80, 1857. 



U8 DISEASES OF THE BRAIN. 

has taken place gradually, and thus time have been afforded for the 
establishment of the collateral circulation. In the first case, not only 
is the blood at once shut off from a portion of the brain, but the vessels 
behind the clot receive a greater quantity than they normally do, and 
hence the regions they supply are immediately congested. In examina- 
tion of the brain of a person who has died during the first stage of 
cerebral embolism, we find those parts of the brain ordinarily supplied 
by the obliterated vessel paler than natural, with a zone of congested 
tissue, and perhaps numerous small extravasations of blood on the 
periphery. 

The place where emboli are most frequently found is, as has already 
been stated, the left middle cerebral artery. The left common carotid 
arises from the arch of the aorta in a line almost exactly coinciding 
with the course of the blood-current. It therefore happens that an 
embolus which has formed on the lining membrane of the heart, and 
which has passed into the aorta after having been detached, enters this 
vessel instead of the innominata. From the common carotid it passes 
into the internal carotid and thence with the stronger and more direct 
current into the middle cerebral artery, which is lodged in the fissure 
of Sylvius. Of forty-two cases of cerebral embolism collected by 
Meissner, in thirty-four the left hemisphere was the seat. Of sixty- 
two cases occurring in my own practice, and to which reference has 
been made, fifty were accompanied with right hemiplegia, and were 
consequently on the left side of the brain. Post-mortem examinations 
were made in eleven of these cases, and in all the embolus occupied the 
left middle cerebral artery. 

Of these latter was the case of a prominent elderly gentleman of 
Providence, Rhode Island, whom I was requested to visit in consul- 
tation with Drs. Parsons and Collins, of that city. Three days be- 
fore, while ascending a hill, he had suddenly become semi-unconscious 
and hemiplegic on the right side. There was also well-marked aphasia. 
When I saw him he was in a state of partial coma, from which he could 
be roused so as to be made to comprehend, but was unable to talk, 
and was entirely paralyzed in the face, arm, and leg, of the right side. 
The clinical history indicated the existence of disease of the left side 
of the heart. I diagnosticated an embolus of the left middle cerebral 
artery, and expressed the opinion that death would ensue within a few 
hours. In both of these views the other medical gentlemen fully con- 
curred. The patient died about eight hours afterward. The post- 
mortem examination was made the following day, and proved the 
correctness of the opinion that had been expressed, for an embolus 
completely occluded the left middle cerebral artery, at the point where 
it divides into the branches which supply the island of Reil and the 
convolutions of the base of the anterior and middle lobes. 

The pathology of the genesis of the clot has already been sufficiently 



PARTIAL CEREBRAL ANJ3MIA, ETC. 149 

dwelt upon in other connections, and the fact that the artery in which 
it is found is not diseased has been mentioned. 

The further consequences of embolism belong to cerebral softening, 
and will be considered under that head. 

Treatment. — It is not necessary to make any remarks on this point 
in addition to those made in regard to the treatment of thrombosis. 
There is very little to be done besides meeting indications as they 
arise, and attempting to relieve the paralysis and other symptoms, for 
which ends my views have been sufficiently expressed in the preceding 
chapters. 

III. THROMBOSIS OF CEREBRAL VEIXS AND SINUSES. 

It was, until the researches of Virchow, generally supposed that the 
coagulation of the blood in the veins was the immediate result of 
phlebitis; but through his investigations it is now very well understood 
that, in the great majority of cases, the inflammation of the veins is a 
consequence of the formation of a thrombus, and not a cause. For 
reasons which will be given further on, the sinuses of the dura mater 
are especially liable to be the seat of autocthonous coagulse. 

Symptoms. — It is very doubtful if venous cerebral thrombosis pos- 
sesses such a characteristic symptomatology as to admit of its being 
identified during the life of the patient. There are headache, convul- 
sions epileptiform in character, paralysis of different parts of the body, 
particularly of the ocular muscles, giving rise to squinting and double 
vision, disturbances of sensibility, and, toward the close of the disease, 
coma. Occasionally there is apoplexy at an early stage. 

Certain symptoms have been laid down by authors as indicative of 
the existence of thrombosis of particular sinuses. Jaccoud, 1 however, 
appears to discredit their importance, and I am disposed to agree with 
him that, though it may be well to know them, it is safer not to attrib- 
ute to them an absolute value. Thus, Yon Dusch 2 asserts that epistaxis 
is symptomatic of obliteration of the superior longitudinal sinus ; Ger- 
hardt 3 finds a difference in the size of the external jugular veins — that 
of the affected side being more collapsed than the other — indicative 
of thrombosis of the lateral sinus ; Griesinger 4 states that the presence 
of a painful circumscribed oedema behind the ear is evidence of the 
existence of thrombosis of the transverse sinus extending into the veins 
which lead to the sigmoid fossa; and Corazza 5 thinks obliteration of 
the superior longitudinal sinus is signified by oedema of the frontal 

1 "Traite de pathologie interne," tome premier, Paris, 1870, p. 149. 
8 Henle und Pfeufer's " Zeitschrift fur ration. Medicin," B. vii., 1859, p. 161. Also the 
New Sydenham Translation — "On Thrombosis of the Cerebral Sinuses," London, 18(>1. 
* Deutsche Klinik, 1857, No. 45. 

4 " Beobachtungen ueber Hirnkrankheiten," Archiv der Heilkunde, 1863. 
B "RevistaClinica," 1866. 



150 DISEASES OF THE BRAIN. 

veins, and exophthalmos. An important point in the symptomatology 
of thrombosis of the encephalic veins and sinuses is the often simulta- 
neous presence of suppurative inflammation of the ear. This is ex- 
plained by the fact that the relations of the mastoid cells and the 
petrous portion of the temporal bone to the lateral, the cavernous, and 
the petrosal sinuses, are so intimate that the extension of a morbid 
process to them, from the parts of the cranium in question, is readily 
accomplished. 

Owing to the inflammatory action so frequently set up in the vein 
or sinus in which a thrombus has been produced, pus enters the gen- 
eral circulation, and hence abscesses are liable to occur in distant parts 
of the body. 

In the very interesting case which forms the basis of Von Dusch's 
important paper, the principal phenomenon observed during the life 
of the patient — an infant nine months old — was a large abscess 
occupying the anterior and outer portion of the right thigh, from which 
half a pint of pus was obtained, by incision, and which continued to 
discharge for several days. Death occurred in a few days without 
being preceded by convulsions, coma, or other head-symptoms. On 
examination after death, the anterior part of the superior longitudinal 
sinus was found to be completely closed by a firm, pale, triangular clot 
of blood, adherent to the walls. Posteriorly the clot did not entirely 
fill the calibre of the sinus, and was softer. Similar clots were also 
found in the left lateral sinus, and in the veins terminating in the 
superior longitudinal sinus. 

In a case reported by Abercrombie 1 as " Suppuration within the 
Left Lateral Sinus," the affection undoubtedly resulted from an exten- 
sion of inflammation from the cranium to the veins. The patient, a 
young lady aged sixteen, complained of severe headache, which ex- 
tended over the whole head. She had an oppressed look, and great 
heaviness of the eyes; pulse 120; tongue clear and moist; face rather 
pale. She had been liable to suppuration of the ears, and the left ear 
had been discharging pus for three weeks; had complained of head- 
ache for a fortnight. A few days afterward, her strength began to 
fail, there was a tendency to stupor, and slight delirium was present. 
There was constant complaint of pain in the head. Finally, she became 
more comatose, but was sensible when roused, and knew those about 
her a few minutes before her death. 

On post-mortem examination the membranes of the brain were found 
congested, but the brain-substance was not diseased. The left lateral 
sinus was inflamed throughout its whole extent. " Its inner coat was 
dark-colored, irregular, and fungous. At one place the cavity was 
nearly obliterated. The disease extended into the torcular Herophili, 

1 " Observations on Chronic Inflammation of the Brain and its Membranes." Edin- 
burgh Medical and Surgical Journal, vol. xiv., 1818, p. 288. 



PARTIAL CEREBRAL ANAEMIA, ETC. 151 

and affected a little the termination of the longitudinal sinus. Behind 
the auditory portion of the temporal bone, near the foramen lacerum, 
and in the course of the left lateral sinus, a portion of the bone nearly 
the size of a shilling was dark-colored and carious on the inner table. 
It was at this place that the sinus appeared to be most diseased." 

It is stated that the walls of the sinus were so thickened as to pre- 
vent the passage of the blood, and that evidently no blood had trav- 
ersed it for some time. Although Abercrombie failed to recognize the 
real nature of the morbid process, there can be no doubt that the sinus 
was closed by an old coagulum, which had been adherent to the walls, 

Prichard l reports the case of a girl sixteen years of age, in whom 
epileptic convulsions had existed for two years, and recurred very fre- 
quently, sometimes several times a day. There appeared to have been 
no other symptoms indicating cerebral disturbance except that it is 
mentioned that at one time she was slightly delirious, and then was 
free from fits. She was treated actively for nine months, and then died 
in a convulsion, of the usual character. 

Examination after death showed that "the left lateral sinus, through 
its whole extent, was filled up by a substance very different in its 
nature from a recent coagulum, and apparently consisting of a deposi- 
tion of lymph, which had become organized. It appeared so com- 
pletely to occupy the calibre of the sinus as to have entirely impeded 
the passage of the blood through it." 

Another case, reported by the same author, 2 is that of a girl twenty- 
two years of age, whose mother had been insane, and whose complaint 
"began by a feverish disorder, under which she labored about nine 
weeks. It was followed by a melancholy and pensive habit. She was 
observed to spend most of her time in reading religious books, and 
attended a meeting of Calvinistic dissenters." When she first came 
under treatment, her appearance was very wild; she was mischievous, 
and fond of destroying her clothes. In about three months and a half 
she was discharged cured, but was readmitted a month afterward, and 
remained in the hospital till her death, which took place about three 
years subsequently. During this period her constitutional tendency to 
scrofula showed itself in a decided manner. The glands of the neck 
were frequently swollen and inflamed, and she was repeatedly attacked 
by pneumonic symptoms. When these disorders became a little 
relieved, her mental alienation was aggravated. She generally sat with 
her hands folded, and her eyes fixed downward. She died from general 
debility and exhaustion, but without additional head-symptoms. 

Post-mortem examination revealed the existence of thickening of 
the dura mater, serous effusion between this membrane and the pia 
mater, fluid within the pia mater, and thickening of this membrane, 

1 " A Treatise on Diseases of the Nervous System." London, 1822, p. 176. 
8 Op. til, p. 357. 



152 DISEASES OF THE BRAIN. 

The substance of the brain was very firm, the pineal gland was large. 
" The longitudinal sinus contained a firm coagulum, resembling a poly- 
pus, which extended into the lateral sinus." 

In only one instance have I had the opportunity of making a post- 
mortem examination in a case of thrombosis of a cerebral sinus. The 
patient, a man forty years of age, had been upon a drunken debauch 
for several days, when he gradually passed into a condition of stupor, 
which was at first mistaken for the continued effect of alcoholic intoxi- 
cation. As it continued for two days after all stimulants had been 
withheld, this idea was abandoned, and the diagnosis of cerebral 
haemorrhage was made. I saw him at this time, and was disposed to 
agree with this opinion. There were profound stupor, stertorous 
breathing, and complete resolution of all the limbs. Much to my 
surprise, however, the state of coma gradually passed off, and as sensi- 
bility returned the patient complained of intense pain in the forehead 
and vertex, which was accompanied by twitchings of the muscles of 
both sides of the face, and of both upper extremities. On the tenth 
day right hemiplegia suddenly ensued, unattended with loss of con- 
sciousness, though there was a slight disposition to stupor manifested as 
soon as the attention failed to be engaged. The pupil of the left eye was 
dilated. On the twelfth day a severe epileptiform convulsion ensued, 
which was succeeded by another on the same day, during which the 
tongue was very severely bitten. Control of the bladder and rectum 
was now lost, and on the fourteenth day the convulsive state became 
permanently established, and the patient died that night without 
regaining consciousness though the convulsions became somewhat less 
violent. 

The post-mortem examination was made the following morning. 
The pia mater and arachnoid were somewhat congested, though the 
subarachnoideal fluid was not notably increased in quantity. The sub- 
stance of the brain was healthy, and there was no extravasation of blood 
anywhere to be found. But, on laying open the longitudinal sinus, 
a firm coagulum was found completely occluding it, from its beginning 
anteriorly, to its termination in the torcular Herophili, partly filling 
this cavity, being attached to its anterior wall, and extending for the 
distance of an inch and a quarter into the left lateral sinus. The 
thrombus was much more dense and compact in its anterior than in its 
posterior part, and that portion which occupied the lateral sinus was 
evidently of more recent formation than the rest. 

A consideration of the symptoms exhibited by these cases will serve 
to show the truth of the assertion made in the beginning of my 
remarks on the subject, that there are no such characteristic symptoms 
of thrombosis of the cerebral sinuses as will suffice for the identification 
of the disease. The most that can be premised is a not very decided 
probability. 



PARTIAL CEREBRAL ANEMIA, ETC. 153 

Causes. — Among the causes of thrombosis of the cerebral veins and 
sinuses, those affections of the heart in which the force of its systole 
is lessened, and those in which there is an obstacle to the return of 
the venous blood, occupy a prominent place. Through the action of 
either of these categories of diseases the circulation within the cranium 
is retarded, the blood tends to accumulate in the large veins and 
sinuses, and, its course being abnormally slow, coagulation is liable to 
ensue. Tumors in the neck, by compressing the internal jugular veins, 
also tend to the same result by backing up the blood in the lateral 
sinus. An intra-cranial tumor may exercise a like effect by direct 
pressure upon a sinus. 

Thrombosis may result from the extension of inflammation from the 
cranium or the cerebral tissue to the sinuses. Such is the case when the 
suppuration of the ear terminates by the formation of a thrombus in 
the lateral, cavernous, or petrosal sinus, or when abscess of the brain 
or an extravasation of blood produces a like effect. The condition in 
question may also be caused by injuries of the skull; it has been known 
to follow the operation of trephining and other surgical procedures on 
the cranium, and may also result from carbuncles, of or near the head, 
and from erysipelas occurring in like situations. 

Age appears to be of some influence as a predisposing cause of 
venous cerebral thrombosis. Thus, of thirty-seven cases cited by Gin- 
trac, 1 fourteen were between the ages of three weeks and ten years, 
eleven between eleven and twenty years, six between twenty-one and 
thirty years, four were forty-five, fifty-five, sixty-five, and sixty-eight 
years old respectively, and two were of advanced age, not exactly 
known. As Gintrac remarks, the nrst period of life is that which is 
most favorable to the occurrence of venous cerebral thrombosis, adoles- 
cence and adult age are a little less favorable, and old age is the least 
so of all. 

Sex seems to be of no predisposing power: of thirty-one cases in 
which the sex was stated, fifteen were males and sixteen females. 

Prognosis. — The elements for forming a prognosis being of a very 
indeterminate character, it is difficult to form an opinion relative to 
the probable result in the case of a person presenting the symptoms 
which have been mentioned. It is perhaps, however, warrantable to 
say that thrombosis of the cerebral veins or sinuses must from the very 
nature of the lesion be a most grave disorder, if not one necessarily 
fatal, sooner or later. If the vein or sinus in which the clot exists be 
small, and if the causes be of such a character as to admit of removal, 
and thus the extension of the coagulation be preventable, the prognosis 
would of course be more favorable than if an opposite state of affairs 
exists. After all, the only data from which a judgment can be formed 
are the severity of the symptoms and the course and duration of the 

1 Op. et he. cii., p. 528. 



154 ' DISEASES OF THE BRAIN. 

disease. The symptoms themselves can be of ver}' little service in this 
respect, for, as we have seen, they have no such pathognomonic value as 
to indicate to us the pathological condition with which we have to deal. 

Diagnosis. — After the remarks already made incidentally with ref- 
erence to this point, there is nothing to say which can elucidate the 
subject. 

Morbid Anatomy and Pathology. — The ordinary seat of the affection 
under consideration, when not the result of some other contiguous 
lesion, is the superior longitudinal sinus ; when due to suppuration of 
the ear, the clot is usually first found in the lateral sinus ; when resulting 
from injury, it has a near topographical relation to the seat. Through 
the occlusion of the sinus it becomes distended on the distal side of the 
clot, and the blood is thus thrown back upon the capillaries and eventu- 
ally upon the arteries. A state of cerebral ischaemia is therefore in- 
duced, to which the symptoms of the first stage of the disease are, in the 
main, to be ascribed. This ischaemia may lead to extravasation of blood, 
to inflammation, or to softening. An increased effusion of serum into 
the sub-arachnoid space and into the ventricles is an almost neces- 
sary consequence. The clot differs in character according to its age. 
When recent, it is soft in consistence and almost black in color, and is 
not adherent to the walls of the sinus in which it is situated. When 
old, it is grayish, dense, and unresisting, and attached to the wall of 
the vessel. If it be divided, a soft, broken-down mass is often found 
occupying the centre. This consists of fat and other elements of the 
regressive metamorphosis which the substance of the thrombus has 
undergone. It was undoubtedly this matter which Abercrombie and 
' other writers mistook for pus. 

Other points in the morbid anatomy and pathology of venous cere- 
bral thrombosis have been sufficiently considered in the remarks which 
have already been made. 

Treatment. — There are no means at present known to science by 
which the affection can be cured, or its consequences prevented. All 
that can be done is to treat the symptoms as they arise, to search for 
their cause, and to remove the latter if removal be possible. Life may, 
in some cases, be prolonged by the judicious use of quinine and stimu- 
lants. Convulsions may be lessened in force and frequency by the em- 
ployment of the bromides, and pain assuaged by hypodermic injections 
of morphia, by a pill containing half a grain of codeia, given at bed- 
time, and repeated if necessary, or by directly taking off a part of the 
intra-cranial vascular tension by leeches to the inside of the nostrils, or 
cups to the nape of the neck. 

IV. EMBOLISM AND THKOMBOSIS OF THE CEREBRAL CAPILLARIES. 

The capillaries of the brain may be occluded either by embolism or 
thrombosis, as are the larger vessels. But the phenomena of these 



PARTIAL CEREBRAL ANEMIA, ETC. 155 

lesions are so indefinite and obscure that it is impossible, in the present 
state of our knowledge, to identify them during the lifetime of the -sub- 
ject. There is, therefore, little to be said relative to partial cerebral 
anaemia resulting from obstruction of the blood in the capillaries, other 
than to call attention to the genesis, the morbid anatomy, and the 
pathology of the processes in question. It will, accordingly, be more 
convenient to consider the subject without subdivision into symptoms, 
causes, etc. 

Embolism of the cerebral capillaries may be the result of deposit 
of pigment, of fat, of pus, or of the debris of various tissues, normal or 
abnormal, which have undergone decomposition. 

Pigment may be deposited in the capillaries whenever the blood — 
as it does in certain diseases — contains an abnormal amount of pig- 
mentary corpuscles. Meckel 1 appears to have been the first to call 
attention to the condition in question. In the case of a lunatic, he dis- 
covered the spleen to be enlarged, and to be covered with dark pig- 
ment. Virchow 2 soon afterward, in the case of a patient who had been 
subject to ague, found the spleen enlarged, black, from excess of pig- 
ment, and the blood in the heart to contain cells with pigment. Meckel 
attributed a great degree of importance to the occurrence of melanae- 
mia — as the blood-disease is called — for the reason that he considered 
the pigmentary obstruction of the capillaries a condition liable to result 
therefrom, and, as a consequence, when those of the brain are thus af- 
fected, the supervention of head-symptoms. Virchow, however, whiles 
admitting the possibility of such a sequence of phenomena, is not able 
to add any facts tending to elucidate the subject. 

Frerichs 3 has called attention to the pigment liver as associated 
with pigmentary emboli in the capillaries of the brain. Thus he says: 
" The next organ in point of frequency to the liver, which undergoes 
important organic and functional derangements, is the brain. Numer- 
ous particles of pigment, which have passed unarrested through the 
vessels of the liver and the lungs, accumulate in the narrow capillaries 
of this organ, and particularly in those of the cortical substance. Even 
by simple inspection of the shade of color, we can form an approximate 
notion of the quantity of coloring-matter which has been deposited, and 
of the extent of the vascular obstruction. We must not, however, rely 
entirely upon inspection, for slight accumulations of pigment in the 
capillaries easily escape notice, particularly when viewed with an un- 
practised eye, and can only be distinguished with the assistance of the 
microscope. In addition to the above, it is not at all uncommon for the 
vessels to become obstructed by a colorless fibrinous-like coagulum 
which of course does not affect the shade of color. The mechanical 

1 Ally. Zeitschrift fur Psychiatrie, 1847, cited by Virchow. " Die Cellular-Pathologie," 
Berlin, 1871, p. 263, and Jaccoud, op. cit., p. 144. 2 Op. cit. 

3 "Kkriik der Leberkrankheiten," Sydenham Society Translation, vol. L, p. 314. 



156 DISEASES OF THE BRALV. 

interruption to the circulation which is produced in this way, not 
unfrequently gives rise to rupture of the small vessels, and the forma- 
tion of numerous capillary apoplexies. Meckel long ago made observa- 
tions of this nature. Planer described eight cases in which small ex- 
travasations were scattered through the gray and white substance of 
the brain. These numerous haemorrhages have not come under my own 
observation ; but in two cases I have observed extravasation into the 
meninges." 

Frerichs states that he has seen three cases in which there were 
functional derangements indicative of material changes in the cortical 
substance of the brain. One of them was that of a lady in her fortieth 
year, who, after an attack of quotidian fever, accompanied by somno- 
lence, suffered from protracted loss of memory. The functions of vege- 
tative life resumed their normal condition, and there were no derange- 
ments of motion or sensation present. The headache and giddiness 
gradually diminished after the removal of the intermittent fever, by 
means of quinine ; but the weakness of memory, and the inability to 
find suitable words for objects and ideas, were still on the increase two 
months after the cessation of the ague. 

Another case was that of a girl, aged nine years, living in the same 
district, where, according to the evidence of two medical men, intermit- 
tent fever, terminating fatally, was at the time very prevalent. This 
girl, whose mental powers had previously been normal, had undergone 
several attacks of tertian fever. After a protracted use of preparations 
of bark, she recovered in her bodily symptoms ; but her mental facul- 
ties gave way, and a state of complete idiocy, accompanied by a raven- 
ous appetite, supervened. 

In regard to these cases, Frerichs further remarks that it is un- 
certain whether atrophy of the brain had resulted from occlusion of the 
capillaries, or whether it had been induced by the extensive capillary 
apoplexies consequent upon this occlusion, or whether the intermittent 
fever was complicated with other accidental changes in the brain. He 
gives the details of several other cases of intermittent fever, accompa- 
nied by head-symptoms, and in which, after death, the cerebral capilla- 
ries — principally those of the cortical substance — were occluded by de- 
posits of pigment, originating in the liver and spleen, and transported 
to the brain by the current of the circulation. 

A case is reported by Bright, 1 of a man, who died of paralysis fol- 
lowing fever, in whom the cortical substance of the brain was the color 
of black-lead. 

Sydenham had not failed to notice the fact that mental derange- 
ment sometimes remains after intermittent fever, which, if treated by 
depletion, passed into imbecility. 

Cases of like character have frequently come under my notice. In 
1 " Reports of Medical Cases," London, 1801, chapter ci., plates xvii. and xix. 



PARTIAL CEREBRAL ANJEMIA, ETC. 157 

one of these there had been repeated attacks of intermittent fever, and 
the spleen was greatly enlarged. The patient, a young man twenty- 
two years of age, had suffered from epilepsy for several months, the 
first paroxysm ensuing shortly after a severe seizure of fever, and being 
preceded by headache, vertigo, confusion of ideas, and twitching of the 
muscles of the face. When I first saw him his mind was considerably 
impaired, and he was having three and sometimes four or five epileptic 
fits every week. All his mental symptoms were improved by the use 
of arsenic; his fits ceased, and his spleen became much reduced in size. 

Those physicians who have practised in malarious regions can 
scarcely have failed to notice the fact that the enlarged livers and 
spleens, which are so frequently produced by repeated febrile attacks, 
are often coexistent with cerebral symptoms, such as have been de- 
scribed. 1 

The vessels of the cortical substance appear to be more liable to oc- 
clusion from pigmentary emboli than any other part of the brain. Some 
recent researches of my own would seem to show that the vessels of the 
retina are also apt to be so obstructed, and that some cases of pigmen- 
tary deposit in the eye are in reality instances of pigmentary embolism 
of the intra-ocular vessels. 

Although the symptoms of the affection in question have nothing 
characteristic about them, yet its existence may be suspected with some 
show of probability, when pain in the head, delirium, convulsions, ver- 
tigo, paralysis, and other disturbances of sensibility and motility, coexist 
with enlarged spleen or liver, and when there is the previous history of 
malarial fever. 

Embolism of the cerebral capillaries from migration of fat is a con- 
dition which certainly occurs, but which has not as yet been very 
thoroughly stadied. Todd, 1 in a woman who died comatose and hemi- 
plegic, found after death an extravasation of blood into the right corpus 
striatum, and that " the vessels of the softened portion of the corpus 
striatum, immediately surrounding the clot, were thickly studded with 
oil-globules, which in some situations were aggregated into dark masses 
so large as here and there almost to fill up the vessels. The minutest 
capillaries, as well as the larger arteries, exhibited these deposits, and few 
could be discovered without them. 

Bergmann, 3 who has devoted much attention to the subject of fat 
embolism, has recently 4 reported a case in which a man, who died in 
consequence of injuries received from a fall, was found to have many 

1 A further consideration will be given to this very interesting subject in the forthcom 
ing memoir of the author, on " Pigmentary Cerebral Embolism, and other Affections of 
the Nervous System the Results of Malarial Poisoning." 

3 " Clinical Lectures," London, 1861, p. 733. 

8 " Zur Lehre von der Fettembolie." Dorpat, 1863. 

4 " Ein Fall tbdlicher Fettembolie." Berliner klinische Wochenschrifl, No. 83, 1873, 



158 DISEASES OF THE BRAIN. 

hemorrhagic extravasations into the lungs, and numerous oil-globules 
in the pulmonary capillaries. The brain does not appear to have been 
examined, but probably the cerebral capillaries would have been found 
in a like condition. 

In order to throw additional light on this subject, I have performed 
a number of experiments upon animals, of which the description of one 
will be sufficient, as the results were analogous in all essential respects. 

Into the left ventricle of the heart of a medium-sized dog sixty min- 
ims of olive oil were injected. 1 The animal was killed six hours after- 
ward by section of the medulla oblongata. The brain was removed 
from the skull and carefully examined. The membranes were decidedly 
congested. The arteries of the base of the brain contained numerous oil- 
globules, and this was especially the case' with both the middle cerebral 

Fig. 15. 





arteries. The minute terminal branches ol these vessels were filled with 
fat, and several of them were entirely occluded. The microscope showed 
the capillaries throughout the brain, both of the cortical and medullary 
substance, to be gorged with fat-globules, aggregated in masses, so as 
to prevent, in many instances, the passage of the blood. 

In other experiments I allowed a longer time to elapse before kill- 
ing the animals, and in one death took place spontaneously during a 
state of profound coma. The post-mortem appearances were more 
strongly marked, and in the latter several centres of incipient softening 
had been set up. 

1 The heart was penetrated through the thoracic wall by the needle of an hypodermic 
syringe, and the injection made very slowly. The left ventricle was chosen in order to 
avoid, as far as possible, the stoppage of the oil in the lungs. 



PARTIAL CEREBRAL ANAEMIA, ETC. 159 

Nothing is known relative to the symptomatology or pathology of 
fat-embolism of the cerebral capillaries, or of the elements of a correct 
diagnosis or prognosis of the affection. 

The cerebral capillaries may be obliterated, as Virchow 1 has shown, 
by deposits of pus or of the debris of organic structures undergoing 
disintegration. Thus a thrombus undergoes such a transformation that 
a purif orm mass originates in its centre through changes taking place in 
the central layers of the clot, and the whole eventually beeomes con- 
verted into a finely-granular substance which is capable of being trans- 
ported to distant parts of the body and occluding the smaller vessels 
and the capillaries; or, for instance, ulceration following endocarditis 
takes place in one of the cardiac valves, as a consequence of acute or 
chronic softening. The minute fragments of the valve are carried away 
by the current of the blood, and are deposited in the vessels of remote 
parts, such as the eyes, the brain, the kidney, and spleen. The accom- 
panying cuts (Figs. 14 and 15) represent these capillary emboli in the 
penicillii of the splenic artery, following endocarditis. In Fig. 14 the 
vessels are magnified ten diameters ; in Fig. 15 three hundred. 

"Whether such emboli are capable or not of transferring specific dis- 
ease to other parts where they are deposited, or whether, as some authors, 
differing from Virchow, assert, they merely act in a mechanical manner, 
is as yet undetermined. The weight of evidence appears to favor the 
view of Virchow, that they act not only by occluding the capillaries, 
but also by their inherent specificity originating new centres of local 
disease. 

Thrombosis. — Thrombosis of the cerebral capillaries may, like the 
same condition of the larger vessels, result from any cause capable of 
inducing a stoppage or retardation in them of the circulation of the 
blood. One of the most common of these factors is calcareous deposit, 
a state which is only to be detected after death, and which, like many 
other analogous morbid processes, was first clearly pointed out by Vir- 
chow. 2 According to him it depends upon the failure of the kidneys to 
excrete the mineral matter which is taken up by the blood from the 
bones, and which in consequence is deposited in other organs. 

Some authors regard calcareous deposit as being a process more anal- 
ogous to embolism than to thrombosis, but it must be recollected that 
the mineral substance is not in a morphological state in the blood, but 
is held in solution up to the time of its separation at the places where 
it is found. It would, in my opinion, be equally logical to regard the 
deposition of fibrine upon the internal coat of a vessel as embolism, 
for it is held in solution till it becomes attached to th'e wall, and in this 
respect does not differ from the condition of the calcareous matter. 

1 "Die Cellular-Pathologie," Berlin, 1871, p. 23*7, et seq. 
8 Op. cit, p. 252. 



1G0 DISEASES OF THE BRAIN. 

In the first place, the serum of the blood holding the mineral sub- 
stance in solution is probably infiltrated through the vascular walls in- 
to the peri-vascular tissue and the deposition effected there. Eventual- 
ly, as the change in the surrounding substance tends to prevent further 
transudation, and as the vessels degenerate from their normal struct- 
ure, the metastatic deposit is made around their internal circumference 
and the channel is finally occluded. At the same time the capillaries 
lose their elasticity and become hard and brittle. The brain in the 
vicinity of these centres of morbid action may be so saturated with the 
calcareous matter as to give a distinct grating sound when cut, and the 
molecules of phosphate or carbonate of lime may even be seen with the 
naked eye and distinctly felt when a portion of the brain is rubbed be- 
tween the fingers. 

Marc6 ' reports the case of a man, fifty-five years of age, who died in 
a state of complete dementia. On post-mortem examination the mem- 
branes were found adherent to the brain; in the centrum ovale of both 
sides there existed large lacunas of a yellow color and with the appear- 
ance of elder-pith. In addition, there were numerous calcareous incrus- 
tations forming sharp protuberances and giving a sensation to the finger 
like that experienced when the tongue of a cat is gently rubbed. The 
capillaries were likewise incrusted. The cerebral substance contained 
several old hemorrhagic /by ers. The calcareous concretions were found 
to consist of crystallized carbonate of lime and of the same substance in 
globular masses. Subjected to the action of dilute hydrochloric acid, 
they were dissolved with the evolution of carbonic-acid gas; an organic 
substance analogous in its characteristics to the corpora amylacea re- 
mained; it was not, however, colored blue by iodine. 

The capillaries surrounding these masses had undergone various de- 
grees of calcareous incrustation. On some, the crystals were scattered 
here and there on the walls ; on others they formed groups or plaques, 
more or less enveloping the circumference of the vessel. There were 
some in which the channel was entirely obstructed by the colorless crys- 
tals, without any other foreign matter, fatty, granular, or pigmentary, 
being present. 

Thrombosis of the cerebral capillaries may also be the consequence 
of atheromatous degeneration and of moniliform dilatation. 

The white substance of the cerebrum, the cortical layer, and the cor- 
pora striata are more liable to be the seats of this process than the 
other parts of the encephalic mass. 

1 "Bulletin de la soti6t6 anatomique," 1863, p. 468, cited by Gintrac, op. cit., p. 473. 



CEREBRAL SOFTENING. 161 



CHAPTER VI. 

CEREBRAL SOFTENING. 



As a consequence of several of the conditions described in the fore* 
going pages, and especially as resulting from thrombosis and embolism 
in their various forms, cerebral softening naturally comes next in order 
for consideration. Most authors treat of it in direct connection with 
obliteration of the cerebral arteries; but, although frequently due to 
this cause, it may be produced by others, and occlusion is not always 
followed by softening. For these reasons I have preferred to consider 
it as it really is, a distinct pathological condition — as much so as sclero- 
sis or any other morbid anatomical state. 

Symptoms. — When softening is the result of haemorrhage, of arterial 
embolism, or of arterial or venous thrombosis or embolism, the symp- 
toms peculiar to those affections are first met with. Thus there are 
troubles of the intelligence, the sensibility, and the power of motion, 
such as have already been described under the heads mentioned, and, if 
the morbid process goes on within the cranium to its full development, 
there are peculiar aggravations and the evolution of new symptoms. 
If coma has existed from the beginning, it may continue with little or 
no remission, and the patient may die without regaining consciousness, 
or may become only partially sensible. The condition of softening is 
not usually set up after either haemorrhage, thrombosis, or embolism, 
till about the tenth day, though some cases are more rapid in their 
progress, and the symptoms now to be mentioned are those which are 
coincident with what some pathologists have designated the "second 
stage;" the "yellow softening" of others. The "first stage," or "red 
softening " of these writers, is, in my opinion, not in reality softening, 
but rather the congestion due to overaction in the collateral circulation. 

In addition to the continued paralysis of motion and the loss of 
sensibility which exist on one side of the body, the mental symptoms 
become more strongly marked. There may be delirium with the occur- 
rence of hallucinations and delusions, though these are generally eva- 
nescent. Occasionally a fixed idea obtains possession of the patient's 
mind, and for a while influences him in his conduct, but his mental 
tenacity is not strong enough to enable him to retain it for any length 
of time, so it soon yields to another. 

The intelligence is notably diminished, so that the patient is unable 
to conceive an exact idea of his situation, or to obtain a moderately 
complete notion of quite simple matters which may be submitted for 
his mental action. Thus he refuses to credit the assertion that he is ill, 
declares that his health, both in mind and body, is excellent, and that 
12 



162 DISEASES OF THE BRAIN. 

he is fully capable of transacting his business or of performing any- 
intellectual operation. 

The memory is invariably impaired, and things of the greatest 
familiarity are forgotten. Thus a patient laboring under cerebral 
softening, the result of embolism, could not tell his wife's name, nor 
by what means he came to my office. Another, sent to me by Dr. 
Michel, of St. Louis, in whom thrombosis was the probable cause, 
could not tell me where he came from, nor the names of his children. 
He insisted with great vehemence that he was perfectly able to at- 
tend to his ordinary business, and yet was unable to add three numer- 
als together. 

In another case, likewise having the clinical history of thrombo- 
sis, which I saw in consultation with my friend Dr. J. W. Ranney, 
of this city, the patient, a gentleman about sixty years old, could 
not tell his age ; declared that Dr. Ranney, whom he had known 
for many years, was a grocer, "who lived around the corner"; and 
held to the delusion that bis sons had made several forcible attempts 
to rob him. 

The power of giving the attention to subjects is very greatly less- 
ened. The patient may seem to be listening to what is said, or observ- 
ing what is passing about him, but, if he be questioned he at once 
shows that he really has not been heeding ; even when things are for- 
cibly brought to his mind, and he is told to mark them, he is incapable 
of doing so to any considerable extent. 

The speech is almost invariably affected either in the form consti- 
tuting aphasia, or from paralysis of the tongue and other muscles con- 
cerned in articulation. There is a disposition to misplace words, or to 
clip them by cutting off the last syllable. Thus a patient reading the 
title of a book in my library called it the " Unit. Stat. Dispenst." for 
United States Dispensatory; another was the "Philosoph. as Absol. 
Scien." for Philosophy as Absolute Science; and he told me he was "a 
lawy. by professi.," when he meant to say he was a lawyer by profes- 
sion. The same fault is shown in reading from a printed page, and in 
writing. Only a few days ago I received a letter from a gentleman, in 
which the final letter of nearly every word was omitted. The emotions, 
especially those of a sorrowful character, are very easily excited, and 
therefore the least untoward event causes the exhibition of feeling. 
Sometimes the patient sheds tears without being able to assign any 
cause, or may get into uncontrollable fits of weeping; occasionally of 
laughing. 

All these symptoms indicate failure of the mental power, but it is, 
nevertheless, true that softening of the cerebral tissue may exist with- 
out the manifestation of the least degree of imbecility. It not unfre- 
quently happens that, while there is a general loss of intelligence, some 
one or two faculties of the mind are notably increased in vigor. 



CEREBRAL SOFTENING. 163 

I have a patient now under my charge whose intellectual force is 
greatly reduced, who cannot pronounce the simplest sentence correctly, 
who is paralyzed throughout the whole of one side, and who has so 
lost the sense of propriety that if he feels the desire to urinate he yields 
to it at once, no matter where he may be or who are present, but whose 
volitional power is even greater than before the accession of his disease. 
Thus he will read volume after volume, turning over the pages regu- 
larly, and scarcely, except by oversight, skipping a word, although it 
is very certain he does not comprehend a tenth part of what he reads, 
and that what he does for a moment understand is immediately for- 
gotten. The strength of his will is also shown in the impossibility of 
inducing him to do any thing which either caprice or habit prompts him 
not to do. His appreciation of harmony has become so sensitive that a 
discord of sounds made on the piano causes him real mental suffering, 
whereas when he was in health his musical taste and discrimination of 
the pitch and quality of sounds were below mediocrity. 

Drowsiness is very generally present; at first, perhaps, to a slight 
extent, but sooner or later as a prominent feature. Headache is very 
common, and is usually dull and circumscribed. The forehead is its 
most common seat. Other sensations in the head, such as vertigo, full- 
ness, weight, and constriction, are scarcely ever absent. 

Gradually, the condition of the patient, mentally and physically, 
becomes weaker and weaker, and death ensues, immediately preceded 
by coma, convulsions, delirium, or a combination of these phenomena. 

Not unfrequently, softening of the brain is not preceded by haem- 
orrhage, thrombosis, embolism, or other evident affection, but begins 
obscurely, and advances very gradually. Such cases are often directly 
due to disease and obliteration of the cerebral capillaries, as described 
in the immediately preceding chapter, or they may be the result of a 
slow inflammatory process. In this form the symptoms make their ap- 
pearance in succession; but the paralysis, instead of being present from 
the inception, comes on very slowly, commencing as a slight weakness, 
conjoined with numbness, in one or more of the extremities, or in the 
face. Ordinarily, the first evidence of paresis is discovered in the leg, 
which is not lifted clear of the ground. The toe consequently strikes 
against the inequalities of the pavement, and the patient is apt to fall. 
Sometimes the weakness is shown by the leg suddenly giving way at 
the knee. I have had several patients with cerebral softening, in 
whom this accident was of common occurrence, and who had thereby 
received severe injuries. Or, when the arm is the paretic member, the 
grasp, as shown by the dynamometer, is materially lessened in strength, 
and things held in the hand are dropped. I have now a patient in 
charge in whom the affection is in its very earliest stages, and of which 
the only manifestations are, clipping of the words in speech and paresis 
of one arm. 



164 DISEASES OF THE BRAIN. 

This inability of the muscles to maintain a continuous contraction 
for a short time, though met with in several other affections, is to some 
extent characteristic of cerebral softening, and, in conjunction with 
the other phenomena, is a valuable indication. Even before it has 
become so far developed as to attract the attention of the patient or 
those about him, its existence may be ascertained by means of the 
dynamometer described in the preliminary chapter of this treatise. 

The paralysis usually goes on to complete loss of power, though its 
progress is often very slow, and is marked occasionally by periods of 
decided improvement. At these times the patient's friends imagine 
that he is about to recover, and if, as is sometimes the case, the mental 
symptoms are likewise mitigated, their hopes are still further exalted. 
It is necessary that the physician should not be deceived. In a case 
which I saw in consultation with Dr. Chamberlain, of this city, I diag- 
nosticated chronic softening. At the time, there were feebleness of 
memory, paresis of one side of the body, and difficulties of speech. I 
gave an unfavorable prognosis, but soon afterward amendment began, 
and the patient, who was an insurance agent or appraiser, resumed his 
business to some extent. I nevertheless adhered to my opinion, for I 
had seen too many cases of similar character to be deceived in so clear 
a one as this. I never saw the patient again, and am therefore unac- 
quainted with the subsequent phenomena, except that about a year 
afterward I was invited by Dr. Chamberlain to be present at the post- 
mortem examination. His brain contained a foyer of softened tissue as 
large as a walnut, apparently the result of obliteration of the posterior 
branch of the left middle cerebral artery, and involving a portion of the 
middle lobe of the left hemisphere. 

In another case, which I had very thorough opportunity for study- 
ing, the patient, a gentleman thirty-five years of age, was the subject 
of chronic softening, without any history of previous lesions. The dis- 
ease had come on very insidiously, first showing itself by a slight im- 
pediment of speech and impairment of memory. Gradually he lost 
power in both arms and both legs, though the right side was more 
affected than the left. His gait became titubating, and although he 
never lost the ability to walk, yet he did so with great and increasing 
difficulty. But his stages of apparent improvement were at first nu- 
merous and well marked. His memory at such times was stronger, his 
countenance brighter, his articulation distinct, his emotions more under 
command, his power of attention increased, his intelligence equal to all 
ordinary occasions, and his walk free from any sign of debility. Then 
all these steps would be suddenly lost, and he would again become 
imbecile and weak. Finally, a severe convulsion, more evident on the 
right side than the left, supervened one evening after dinner, as he was 
quietly smoking a cigar. Between seven and twelve o'clock that night 
he had over a hundred fits. He died at the latter hour. The post- 



CEREBRAL SOFTENING. 165 

mortem examination revealed the existence of a large centre of soft- 
ening, involving the middle lobe of the left hemisphere. 

Sometimes the course of the disease is still more irregular. No 
evidence of cerebral disorder is perceived beyond aphasia, and the 
patient remains in the full possession of his intellect, and without pa- 
ralysis, up to a short time before death. Durand-Fardel 1 cites the case 
of a man, thirty years of age, who entered the Hotel Dieu, presenting 
all the signs of pulmonary phthisis. In a few days afterward he expe- 
rienced difficulty of articulation, in thirty hours he became comatose, 
and, in twenty more, died. The post-mortem examination revealed the 
existence of softening of the inferior surface of the left middle lobe 
of the cerebrum. Although it is not so stated — Durand-Fardel hav- 
ing written previous to Virchow's observations — there is little doubt 
that the cause of the softening was an old embolus in the left middle 
cerebral artery. 

Lallemand, 8 in his first letter, cites several cases in which the dis- 
ease was marked by singular symptoms, such as convulsions, contrac- 
tions, and delirium. 

In a case which I saw in consultation with Prof. 0. A. Budd and 
Dr. J. T. Taylor, occurring in a gentleman about thirty-five years of 
age, there were coma and violent hemi-convulsions, evidently due to 
softening from embolism, of which there had been two attacks, the 
last several weeks previously. Death ensued, but no post-mortem ex- 
amination was, I believe, obtained. 

A gentleman is now under my charge who has valvular disease on 
the left side of the heart, the consequence of rheumatic endocarditis, 
and who, six months since, had an apoplectic attack conjoined with 
aphasia and right hemiplegia. He soon became able to speak pretty 
well, and regained power and sensibility to a great extent in the para- 
lyzed limbs. During the past two weeks, however, he has exhibited 
symptoms of mental derangement, as shown by the existence of hal- 
lucinations and delusions, and is gradually losing the power of motion 
and of sensation on the right side. His speech is as perfect as it ever 
was, and there is yet no sign of dementia. 

It has happened that individuals have died who, on post-mortem 
examination, were found to have softening of the brain, but who, 
during life, had exhibited no symptoms of this or any other cerebral 
disorder. Rostan, who was the first to write systematically on the 
disease, refers to such cases, and Durand-Fardel is still more explicit. 
The latter says : 

" We meet with softening of the brain in persons who, up to the 
time of death, had presented no appreciable derangement of the cere- 

1 " Traite du ramollissement cerebrale," Paris, 1843. 

2 " Recherches anatomico-pathologiques sur l'encephale et ses dependances," Paris, 
1824. 



166 DISEASES OF THE BRAIN. 

bral functions, and in whom softening has been developed without 
having given any evidence whatever of its existence." In such in- 
stances the white matter of the hemisphere can alone be involved. 

One such case verified by post-morten examination has occurred 
within my own experience. The patient, a soldier of the Second United 
States Infantry, died at Fort Riley, in Kansas, of which post I was 
medical officer, of chronic dysentery, the result of exposure. There 
were no mental symptoms, no difficulty of speech, no paralysis; nothing, 
in fact, indicating the existence of brain-disease. He died in full pos- 
session of his intellectual faculties. The post-mortem examination re- 
vealed the existence of ulceration of the small intestines, and, as the 
cause of death was very evident, the brain was ncjt examined. I re- 
served it, however, for purposes of study, and, on making a section of 
the right hemisphere an hour afterward, discovered an encysted centre 
of softening, including more than two-thirds of the posterior lobe. The 
right posterior cerebral artery was entirely obliterated by thrombosis. 
The man had been at the fort several months, and had never made 
complaint of any illness till he was attacked with dysentery six weeks 
before. 

The duration of cerebral softening is very variable. Rostan found 
it to range from a few days to several years. Andral," from an analysis 
of one hundred and five cases, found that the period was from twelve 
days to three years. The most rapid case occurring in my experience 
terminated in death at the end of eighty hours. Some confusion on 
this point has arisen from the fact that some authors regard embolism 
and thrombosis as essentially identical with softening, a doctrine which 
is clearly erroneous, as, in many cases of these affections, recovery or 
death may take place without the stage of softening being reached. 
In the case above referred to, post-mortem examination showed that 
the condition known as yellow softening was just making its appear- 
ance. As I have already stated, I cannot regard the alteration called 
by some pathologists red softening any thing more than the congestion 
due to the active collateral circulation. 

The case of longest duration, of which I have any personal knowl- 
edge, was that of an eminent scientific gentleman, who had suffered 
from the symptoms of softening of the brain for nearly four years, when 
he died. There was no post-mortem examination, but the history of 
the case was that of thrombosis of the left middle cerebral artery, and 
the course of the disease left no room for doubt as to its nature. 

The symptoms of cerebral softening which I have specified are 
those which are in general the result of the morbid processes existing in 
the cortical substance of the hemispheres, or in the optic thalami, o^ 
corpora striata. Generally, as Laborde 1 has shown, whenever the corti" 

1 " Le ramollissement et la congestion du cerveau principalement considered chez le 
vieillard," Paris, 1866, p. 1, et seq. 



CEREBRAL SOFTENING. 167 

cal substance is the seat of softening there is at least one other centre 
occupying the central part of the brain, or especially the corpus stria- 
tum or optic thalamus. But the other portions of the encephalic mass 
are liable to be similarly affected, and then the phenomena are of a dif- 
ferent character. 

Thus the pons Varolii may undergo softening from occlusion of the 
basilar artery, or of one or more of its transverse branches, or from disease 
of its capillaries, or from chronic inflammation of its substance, and if the 
disease be limited to this ganglion there is no marked mental deteriora- 
tion or other evidence of intellectual derangement. The symptoms are 
in the main connected with sensibility, and the power of motion with ar- 
ticulation, and with the respiratory, circulatory, and stomachal functions, 
as evidenced by dyspnoea, irregular action of the heart, and nausea and 
vomiting. In the case of an elderly gentleman whom I saw in the early 
part of 1874, and who had been affected for about a year, there was 
almost complete paralysis of the lower part of the face on both sides, 
there was great difficulty of swallowing, the tongue could not be pro- 
truded, speech was very indistinct, the respiration and action of the 
heart were irregular, and the limbs were partially paralyzed. There was 
a general loss of sensibility throughout the whole body, and attacks of 
vertigo and epileptiform convulsions had been frequent. At the same 
time the intellect was as clear and exact in its operations as it ever had 
been. I diagnosticated glosso-labio-laryngeal paralysis, and expressed 
the opinion that the patient would not live over a month. He died in 
two weeks. The post-mortem examination showed the hemispheres and 
cerebellum and the membranes to be healthy. The basilar artery was 
entirely closed by a thrombus. The pons Varolii was as soft as cream, 
and the membranes peeled off as easily as if they had never been at- 
tached to it. Examined microscopically after due preparation, the cap- 
illaries were found to be in a state of atheromatous degeneration. The 
medulla oblongata was not softened, but extreme atrophy of nerve-cells 
had taken place in the nuclei of the facial nerve of both sides. This 
point will be further considered under the head of atrophy of nerve-cells. 

Softening of the cerebellum can scarcely, in the present state of our 
knowledge, be diagnosticated from any other affection of that organ. 
The rapid form, such as results from embolism of the larger vessels, pre- 
sents so many analogies with haemorrhage that there are no sure signs 
by which a discrimination can be made; and the slow form due to disease 
of the capillaries or to chronic inflammation is not distinguished from 
abscess or tumor. But it may be inferred that the cerebellum is the 
seat of structural change when the category of symptoms cited under 
the head of cerebral haemorrhage is present, and the history of the case 
will often aid us in forming an opinion of its nature not very wide of 
the mark. 

When death results from cerebral softening, it may be directly due 



168 DISEASES OF THE BRAIN. 

either to the disease itself, or to some intercurrent affection. Thus the 
patient may die from pure exhaustion or from slow asphyxia caused by 
the imperfect action of the respiratory function, or he may choke to 
death either by being unable to swallow food which he has taken into 
his mouth, or by the regurgitation of the contents of the stomach during 
a convulsion, or a severe convulsive seizure may cause immediate as 
phyxia, or a series of convulsions may produce a more gradual asphyxia, 
or he may die in a state of profound coma. 

The intercurrent affections may be either meningitis or hypostatic 
congestion of the lungs from long confinement to the recumbent pos- 
ture, or diarrhoea, or a fresh attack of thrombosis or embolism. 

Causes. — The etiology of cerebral softening has already been con- 
sidered to some extent under the heads of cerebral haemorrhage, and 
obliteration of cerebral arteries and veins and of the capillaries, from 
embolism and thrombosis, of which conditions it is so often a sequence; 
but, as it may occur without having been preceded by either of these or 
other noticeable affections, a few additional observations are necessary. 

Age is certainly a strong predisposing, if not an actual exciting 
cause, although the disease is observed at all periods of life. Rostan, 
whose cases were collected at the Salpetriere, a hospital containing only 
old women, found that there were ten cases in persons between the ages 
of sixty and sixty-nine, twenty between seventy and seventy-nine, and 
ten between eighty and eighty-seven. Andral, excluding cases occur- 
ring in infants, found that, of one hundred and fifty-three cases, there 
were between the ages of 

15 and 20 10 

20 " 30 18 

30 " 40 11 

40 « 50 19 

50 " 60 27 

60 " 70 34 

70 " 80 30 

80 " 89 4 

Durand-Fardel, from an analysis of fifty-five cases, found between 
the ages of 

30 and 40 3 

40 " 50 8 

50 " 55 2 

60 " 70 14 

70 " 80 23 

80 " 87 5 

The period of life, therefore, at which softening is most apt to occur, 
is from the age of fifty to eighty. 

During the past ten years, foiiy-five cases of cerebral softening, not 



CEREBRAL SOFTENING. 169 

the result either of hemorrhage, arterial embolism, or of arterial or ve- 
nous thrombosis, have been under my care or been seen by me in consulta- 
tion. Of these, one was under twenty years of age ; four were between 
twenty and thirty years; nine between thirty and forty; twelve between 
forty and fifty; eight between fifty and sixty; eight between sixty and 
seventy; and three between seventy and eighty. The general results, 
therefore, go to show the greater proclivity which advanced age gives 
to the occurrence of the disease. In one of those between seventy and 
eighty, the mind was scarcely impaired till about two months before 
death, though there had been paresis, headache, and aphasia, for two 
years. 

No definite statistics have been collected relative to the influence of 
sex, although the opinion appears to prevail that the affection is more 
liable to occur in females than in males. Of the forty-five cases just 
cited, twenty-nine were males and sixteen females. 

The season of the year does not appear to exercise much influence. 
Durand-Fardel, from sixty-three cases, found that seventeen occurred in 
winter, thirteen in spring, twenty in summer, and thirteen in autumn. I 
have found it difficult in many cases, from the insidious or latent charac- 
ter of the early symptoms, to fix the period of beginning with accuracy. 

Intense and long-continued intellectual exertion is one of the most 
common causes of cerebral softening. Eleven of the cases occurring in 
my experience were clearly the result of this cause. Severe and pro- 
tracted emotional disturbance was apparently the cause in four cases. 

Rostan, among the causes, cites insolation, the action of intense cold, 
blows upon the head, and excessive use of alcoholic liquors. 

The influence of obliteration of the cerebral arteries, sinuses, veins, 
and capillaries, in producing partial cerebral anaemia, and hence as lead- 
ing to the supervention of softening, has already been dwelt upon at suf- 
ficient length. 

Diagnosis. — The history of haemorrhage, thrombosis, or embolism, 
when these conditions have either of them given rise to softening, will 
aid in the diagnosis. The signs which serve to distinguish these affec- 
tions from others have already been amply considered. 

When there is no such previous clinical history, softening of the 
brain may be confounded with chronic meningitis, meningeal haemor- 
rhage, or tumors. From chronic meningitis it is to be distinguished in 
many cases by the facts that in the former the headache is generally 
diffused, while in softening it is fixed, that the paralysis is more limited, 
that there are frequent spasms of the limbs, that there are well-marked 
febrile exacerbations, and that there is not the progressive enfeeble- 
ment of the intellect so characteristic of the vast majority of cases of 
cerebral softening. At the same time it must be admitted that the diag- 
nosis sometimes cannot be clearly made out. 

In meningeal haemorrhage coma occurs as an early symptom, gradu- 



170 DISEASES OF THE BRAIN. 

ally increasing in intensity, whereas in softening it comes on at a late 
period. Hrematoma of the dura mater, however, may readily be con- 
founded with softening. The history of the case will aid in the forma- 
tion of a correct diagnosis. 

In tumors the most prominent symptoms are pain and convulsions, 
while the intellect usually remains unaffected. The pain is exceedingly 
intense, while in softening it is dull. The speech in tumors is generally 
unaffected. 

Prognosis. — Cerebral softening in general ends in death. Neverthe- 
less, it is not altogether hopeless. If' the patient be young, of good 
constitution, and of temperate habits ; if the centre of softening be 
small, and not involving the more important parts of the brain, there is 
some encouragement to expect a favorable termination. Some of the 
cases cited in this chapter go to show that recovery is possible, and I 
have certainly seen others with the ordinary initial symptoms of cere- 
bral softening recover with appropriate medication. Such patients, 
however, were all under the age of forty, and were of good constitution 
and habits. In softening due to embolism, and occurring after rheuma- 
tism and endocarditis, the liability to future attacks must not be over- 
looked. I have seen as many as six attacks of embolism occurring in 
the same patient, and yet no morbid condition beyond that of anaemia 
set up, and again cases in which a single embolus has caused softening 
and death. 

Morbid Anatomy. — In the softening of the brain which results from 
the obliteration of arteries or veins by embolism or thrombosis, the first 
stage after that of congestion from the excessive action of the collateral 
circulation is what is called yellow softening. This is not, as some 
authors have supposed, produced by the infiltration of pus into the 
cerebral substance, but is caused by regressive metamorphosis of the 
brain-cells into fat, the granules of which are mixed with the coloring 
matter of the blood which gives rise to the peculiar yellow color. The 
white corpuscles of the blood also undergo degeneration .into fat. 

These altered white corpuscles were described by Gluge ' as inflam- 
mation corpuscles, under the idea that softening was always the result 
of inflammation. Laborde, 2 who has studied this subject with great 
success, shows, however, very conclusively that the transformation is a 
true degeneration, a part of the fat-corpuscles being derived, as stated 
above, from the nervous fibres, the cylinders of which disappear, the 
contents being extra vasated, and with the myeline being converted into 
fat; and another part consisting of altered white blood-corpuscles. At 
this time the cerebral tissue is pulpy, constituting a centre of softening 
or a, foyer, the consistence of which is greater at the circumference than 
at the centre. The blood-vessels passing through the disorganized por- 

1 " Atlas of Pathological Histology." Translated by Leidy. Philadelphia, 1855. 
8 Op. cit. 



CEREBRAL SOFTENING. 171 

tion are easily separated from the perivascular tissue and are covered 
with oil-globules. 

The second stage is designated white softening, and in it the brain- 
substance loses altogether its morphological characteristics, and appears 
as a white, cream-like matter so soft that a weak stream of water, al- 
lowed to impinge upon it, washes it away. In this semi-liquid matter, 
whitish flakes of denser tissue are suspended. Microscopical examina- 
tion shows that all traces of nervous structure have disappeared, and 
that no anatomical elements remain except oil-globules and organic cor- 
puscles somewhat resembling leucocytes. 

"When the morbid process involves the cortical substance of the 
cerebrum, the convolutions undergo a peculiar kind of transformation 
first pointed out by Cruveilhier, and then by Durand-Fardel * as occur- 
ring in the senile form of softening. 

This is characterized by the formation of yellow plates, irregular in 
form, soft to the touch, but yet sufficiently dense to resist the action of 
a thin stream of water. Microscopically they are seen to consist of 
nucleated fibres, fat-corpuscles, fat-globules, and degenerated capillaries, 
with blood-crystals and granular matter. Essentially, therefore, they are 
formed of connective tissue. 

The degenerated nerve-tissues, constituting a focus of softening, 
may undergo absorption. In such a case, a cicatrix, similar in general 
characteristics to that resulting from the curative process of haemorrhage, 
remains. 

In the softening resulting from inflammation, a somewhat different 
set of morbid appearances exists. Thrombosis and embolism produce a 
true death of the parts previously supplied by the occluded vessels, a ne- 
crobiosis, as it has been called by Virchow. The process is accompanied, 
as we have seen, by degeneration of the nervous tissue, but in the soft- 
ening due to inflammation new formations result. Sometimes the two 
coexist, but the latter is occasionally an entirely independent action. 

When such is the case, connective tissue is generated, and the ner- 
vous substance is rapidly broken down. An exudation of an albumi- 
nous fluid containing fine granules, the disintegrating nervous substance 
and numerous flakes of coagulated fibrine, takes place, and with blood- 
corpuscles causes the centre of softening to present the appearance of a 
reddish pultaceous mass, easily washed away by the action of a weak 
stream of water. With age the color of this softened tissue becomes 
brown or yellow. Sometimes, when the inflammation has extended to 
the deeper parts of the cerebrum, the contents of the cyst are pene- 
trated by the new connective tissue. The pulpy mass undergoes partial 
absorption, and is replaced by a white turbid liquid, called by Cruveil- 
hier and Dechambre "milk of lime" (lait de chaux). Durand-Fardel 
designates this form of softening " cellular infiltration." 

1 " Maladies des vieillards," Paris, 1854, p. 72. 



172 DISEASES OF THE BRAIN. 

The softening resulting from occlusion of the capillaries, a condition 
not recognizable during life, does not differ essentially, except in its 
situation, from that which follows embolism or thrombosis of the larger 
vessels. The centres of the process are, however, smaller, are generally 
numerous, and usually met with either in the cortical or white sub- 
stance, or in the corpora striata. The morbid anatomy of the affected 
vessels has been sufficiently considered in the previous chapter. 

When disease of the capillaries has been the cause of the softening, 
these may be ruptured, and we meet with minute extravasations of 
blood in the disintegrated perivascular tissue, constituting the " capillary 
hemorrhage " of Cruveilhier. 

Pathology. — The first definite accounts of cerebral softening were 
given by Lallemand l and Rostan, 3 both of whom published their works 
in the same year, 1820. 

In the very beginning of his first letter, Lallemand awards to MM. 
Recamier, Bayle, and Cayot, the credit of describing the condition under 
consideration, and of giving it the designation by which it is so general- 
ly known, even out of France, of ramollissement. Lallemand then pro- 
ceeds to define the term by saying that, by ramollissement of the brain, 
he understands a kind of liquefaction of a part of its substance, the re- 
mainder preserving its ordinary consistence. He then quotes cases 
from Morgagni and Abercrombie, and cites others from his own experi- 
ence; and then concludes by declaring that he does not hesitate to 
range cerebral softening among the inflammations, in which opinion he 
is supported by Abercrombie. 3 Rostan 4 regarded the disease as some- 
times being due to inflammation, and sometimes to degeneration of the 
blood-vessels. Bouillaud 6 viewed it as an anatomical feature of inflam- 
mation. Cruveilhier 8 considered what he called red softening as result- 
ing from the capillary haemorrhage previously mentioned, and that other 
forms were certainly due to inflammation. 

Andral 7 recognized the fact that softening might result from inflam- 
mation or capillary haemorrhage, but he also insisted that it might be 
due to special alterations of nutrition, caused by different morbid influ- 
ences, such as obliteration of the arteries supplying the brain, or im- 
poverishment of the blood. 

MM. de la Berge and Monneret 8 adopted in part the views of Ros- 
tan relative to degeneration of the cerebral vessels as a cause of soften- 

1 " Recherches anatomico-pathologiques sur l'encephale," Paris, 1820. 

2 "Recherches sur le ramollissement du cerveau," Paris, 1820. My references to 
Rostan's work are to the second edition, of 1823. 

8 Op. cit., p. 205. 4 Op. cit., chapter vii. 

6 "Traite de l'encephalite," Paris, 1825. 

6 Art. " Apoplexie," in " Dictionnaire de medecine et de chirurgie pratiques." 

7 " Clinique medicaid" 

* " Compendium de medecine pratique." 



CEREBRAL SOFTENING. 173 

ing. Carswell ' regarded softening occurring during life as being af- 
fected by these circumstances — inflammation, obliteration of arteries, 
and modification of nutrition. 

Fuchs 2 appears to think that inflammation is not a necessary ante- 
cedent, but that congestion is. He also admits obstruction of the 
arteries at the base of the brain to be a cause. 

The studies of Durand-Fardel 3 have been very thorough, and have 
contributed greatly to our knowledge of cerebral softening. According 
to him, the affection is an inflammation which does not differ essentially 
from other inflammations occurring in the young or old. White soften- 
ing he regards as the chronic form of the disease. 

Other pathologists published the results of their observations and 
generally to the same effect as those which have been quoted, viz., that 
cerebral softening was an inflammatory process, and sometimes one re- 
sulting from obliteration or disease of the arteries. A few, however, 
held to the view of Lallemand and Durand-Fardel, that inflammation 
was always the starting-point. 

In 1847 Virchow published his observations relative to embolism, and 
the partial cerebral anagmia produced by occlusion of an artery thus be- 
came a recognized fact. In reality, it came to be regarded as the only 
cause capable of giving rise to softening, and many pathologists of the 
present day entertain such an opinion. But I think this is carrying the 
theory further than facts will warrant. I cannot altogether disregard 
the researches of Durand-Fardel, 4 Calmeil, 5 Rokitansky, 6 Wedl, 7 and 
others, and although I cannot agree that all cerebral softening is a con- 
sequence of inflammation, I am very sure it has this and other causes 
besides thrombosis and embolism. Calmeil's work is a monument of 
careful observations and scientific deductions, and his fifth chapter (tome 
ii.), entitled " Du ramollissement cerebral local aigu, ou de Venchpha- 
lite locale aigue sans caillots sanguins siigeant sous la forme oVxin foyer 
ou des plusieurs foyers circonscrits, soit a la surface, soit dans la pro- 
fondeur de la masse enckphalique" contains cases which are amply 
sufficient to establish the point for which he contends. He shows, too, 
in other chapters of his treatise, that softening results about the periph- 
ery of clots due to cerebral haemorrhage. 

The weak feature of Calmeil's otherwise very complete work is, that 
he altogether ignores Virchow, and those after him, who have confirmed 
his facts and theories. 

1 Art. " Softening of Organs," in " Cyclopaedia of Practical Medicine," vol. iv., p. 176, 
American edition. 

2 " Beobachtungen und Bemerkungen iiber Gehirnerweichung," Leipzig, 1838. 

3 " Traite du ramollissement du cerveau," Paris, 1843. 

4 " Maladies des vieillards," Paris, 1854. 

6 " Traite des maladies inflammatoires du cerveau," Paris, 1859. 

6 " Pathological Anatomy," Sydenham Society translation, 1850. 

7 " Rudiments of Pathological Histology," Sydenham Society translation, 1855. 



174 DISEASES OF THE BRAIN. 

Soulier, 1 on the other hand, can see in softening nothing of the 
nature of inflammation. For him it is always a necrobiosis, produced 
by the cessation of the physiological action of the blood, obliteration by 
embolus or thrombus, by diminution of the calibre of the vessels, or oc- 
clusion resulting from atheroma or obstruction of a vein or sinus. He 
admits that the obliteration of an artery may cause congestion behind 
the point of obstruction, by which the coagulation and capillary haemor- 
rhage of acute softening — the capillary apoplexy of Cruveilhier — are to 
be explained. This red ramollissement ' has, however, nothing of the 
nature of inflammation about it. 

The only points in which I differ with Soulier are, that I cannot 
regard softening as being solely due to occlusion of blood-vessels, and 
that I am very sure the congestion which follows thrombosis or embo- 
lism is not necessarily the first stage of softening. There is no more 
reason why partial cerebral anasmia should always result in softening, 
than that ligation of the femoral artery should always lead to gangrene 
of the parts below. 

Obstruction of veins and sinuses in the brain may be followed by 
softening. The clot is usually the result of injuries or disease of the 
cranial bones or cerebral membranes, especially the dura mater. It may 
also be caused by certain cachectic conditions in which the blood is 
deteriorated in quality, such as typhus and typhoid fevers and 
cholera. 

Four cases, in which this latter affection was followed by thrombo- 
sis of the superior longitudinal sinuses, with consecutive softening, have 
come under my observation. In two of them there were also thrombi 
in both femoral veins. The upper surfaces of both hemispheres were 
the seats of the softening, which involved the gray matter only. 

Thrombosis of the veins or sinuses may also in general terms be 
produced by whatever cause is capable of retarding the current of 
blood. Mr. Toynbee, 2 in his chapter on diseases of the mastoid cells, 
has brought forward several cases in which the lateral sinus was occluded 
by coagula, and in which there was cerebral softening. 

Cerebral softening may also result from the formation of adven- 
titious growths, or from the presence of foreign bodies in the brain. 
In such cases the process begins with inflammation, and is similar to 
the action which sometimes goes on around an extravasation of blood. 

Acute cerebritis or meningitis may likewise result in softening. 
This fact is admitted by Drs. Russell Reynolds and Bastian, in their 
admirable essays on cerebritis and softening of the brain, though with 
evident reluctance. 

We see, therefore, that cerebral softening may be caused either by 
anosmia or inflammation, and that it is of two kinds, inflammatory and 

1 Journal de medecine de Lyon, Fevrier, 186*7. 

8 u Tiie Diseases of the Ear, their Nature, Diagnosis, and Treatment," London, 1860. 



CEREBRAL SOFTENING. 175 

non-inflammatory. The seat of the softening may be in any part of the 
brain, although some regions are more liable than others. When due 
to thrombosis, there appears to be no predilection for any particular 
location, but, as embolism is generally found on the left side in the 
middle cerebral artery, the parts of the brain supplied by this vessel 
are more liable than the corresponding parts of the right side. 

Durand-Fardel, however, did not arrive at this conclusion. Of one 
hundred and sixty -nine cases of softening, he found the left hemisphere 
the seat in sixty -nine, the right in seventy -one, both in twenty -six, and 
the middle line in three. 

The gray matter is generally supposed to be more frequently the 
seat of softening than the white. It is true that, of thirty-three cases 
of acute softening observed by Durand-Fardel, 1 the convolutions were 
involved in thirty-one, but in nine only were they the sole part af- 
fected. 

In fifty -three cases which the same author collected from the writ- 
ings of Rostan, Lallemand, and others, the centres of softening were 
found to be as stated in the following table. Occasionally more than 
5ne region was involved. 

Convolutions and white substance 22 

Convolutions alone 6 

"White substance alone 5 

Corpus striatum and optic thalamus 6 

Corpus striatum alone 11 

Optic thalamus alone 4 

Pons Varolii 3 

Crux cerebri 1 

Corpus callosum . . 1 

"Walls of the ventricles (septum) 1 

Fornix 1 

Cerebellum 1 

Rostan, on the other hand, found the corpora striata and the optic 
tnidaaii to be the parts most frequently affected, and after these the 
central part of the hemispheres. He met with but few cases involving 
the median line. 

As regards the frequency with which the convolutions with the 
white substance were involved, as compared with the motor tract, ho 
found that, of one hundred and seventy-seven cases of acute and 
chronic softening, the convolutions and white substance were affected 
in one hundred and nineteen, and the corpora striata and optic thalami 
in fifty eight. 

The middle lobe is more liable than any other, as is seen in the fol- 
lowing statement of Durand-Fardel, based upon an analysis of ninety- 
five casxis: 

1 " Traite du ramollissement du cerveau," Paris, 1843. 



176 DISEASES OF THE BRAIN. 

Posterior lobe 18 

Middle 51 

Anterior 18 

Posterior and middle 7 

Posterior and anterior 2 

Middle and anterior 2 

Whole convexity of hemisphere 1 

Middle line 1 

Tn more than one-half of the cases, therefore, the middle lobe was 
the seat of the disease. 

A question connected with the pathology of cerebral softening, as 
with haemorrhage, is, " Can we determine, from a consideration of the 
symptoms, what part of the brain is the seat of the lesion ? " The 
answer must be the same. We can do so with some approach to ac- 
curacy, but, till we are better acquainted with the physiology of the 
different ganglia composing the brain, we cannot expect to do so with 
absolute certainty. Indeed, owing to the greater extent of tissue in- 
volved, compared to that affected in haemorrhage, we have a more com- 
plicated set of phenomena to deal with. I have nothing further to 
add to the remarks made on a similar point, under the head of cerebral 
haemorrhage. 

Treatment. — The treatment proper for cerebral softening should de- 
pend very much upon the cause from which it has arisen, and must 
more or less be directed against the symptoms which are manifested. 
Thus, if there is reason to suspect the existence of thrombosis or embo- 
lism, and a consequent anaemic condition of a portion of the brain, the 
judicious use of stimulants and tonics is advisable, while the body should 
be kept warm by additional clothing, or the application of artificial 
heat — at the same time the recumbent posture should be assumed, and 
the head supported on a low pillow. Mental exertion should, of course, 
be absolutely interdicted. If there be much headache, it is probably 
due to too great an activity of the collateral circulation, and in such a 
case some one of the bromides may be given in large doses, repeated as 
often as may be necessary. I have frequently seen great relief follow 
their administration. 

Delirium is often due to a like cause and may be similarly treated. 
Dr. Reynolds * speaks highly of the Indian hemp in doses of a quarter 
to half a grain of the extract; but I have found the bromide of potas- 
sium, in doses of thirty grains every three or four hours, more effica- 
cious. It is also the most beneficial remedy in the convulsions which 
frequently precede a fatal termination. 

In that form of softening which is obscure in its origin and gradual 
in its progress, there is a little more hope of a favorable result, though 
even here it must be confessed that treatment is not often effectual. 

1 Article, "Softening of the Brain," in " System of Medicine," vol. ii. 



CEREBRAL SOFTENING. 177 

Still, as I have said, when speaking of the prognosis, there are un- 
doubtedly cases in which recovery has taken place, and I am very sure 
that I have several times succeeded in curing individuals who, so far as 
I have been able to judge, were affected with cerebral softening. As 
these cases are interesting in themselves, and as the histories will show 
the means of treatment employed, I do not hesitate to transcribe the fol- 
lowing typical ones from my case-book: 

I. — Mr. R., a gentleman, twenty-four years of age, awoke one morn 
ing about the middle of March, 1870, with a sensation of numbness ex 
tending through the whole of the left arm and leg, and with a feeling 
of vertigo which was insupportable when he arose from the bed. He 
sat down in a chair, and while in this position was conscious of a buzz- 
ing sound in the right ear. In the course of half an hour the vertigo 
passed off, but the numbness and sound in the ear remained, and he oc- 
casionally saw double. In a few days afterward he noticed a slight 
difficulty of articulation, owing to apparent thickness of the tongue, and 
about the same time observed that in the morning the pillow was wet 
with the saliva which had run from his mouth during sleep. His uncle, 
a wealthy gentleman of this city, sent him off traveling, but he returned 
in a few weeks with loss of power in the left arm and leg, which had be- 
gun to be manifested to a slight extent before his departure. He came 
under my charge May 15, 1870. 

At this time the paralysis, of both motion and sensation, was well 
marked on the left side, as shown by the aesthesiometer and dynamom- 
eter. The line made by the dynamograph with the right hand was 
perfectly straight, while that made by the left was at an angle of forty- 
five degrees with the other. In his conversation he clipped his words, 
and sometimes left out the smaller ones. His memory he stated was 
materially impaired. There was almost constant headache over the 
whole frontal region, and attacks of vertigo were frequent. There was 
no marked paralysis of the face, though the muscles of both sides were 
paretic, and he often had double vision. The right pupil was largely 
dilated and was insensible to light. 

Ophthalmoscopic examination showed the left eye to be perfectly 
normal, but the retinal vessels of the right were smaller and straight, 
and the choroid was paler than natural. 

Upon inquiry I ascertained that he had given extraordinary atten- 
tion to his business for a period of several months before the attack of 
numbness, frequently being up making calculations till three o'clock in 
the morning, and thus depriving himself of the necessarv amount of 



My opinion was, that he was suffering from incipient softening of 
the brain due to disease of the capillaries, which, in its turn, resulted 
from cerebral congestion and exhaustion. I was further of the opinion 
that the lesion involved the right hemisphere and motor tract. 
13 



178 DISEASES OF THE BRAIN. 

I prescribed the phosphide of zinc in the dose of the tenth of a 
grain, with half a grain of extract of nux-vomica in pill three times a 
day, with the constant galvanic current three times a week, the latter 
to be derived from fifteen of Smee's cells, and to be passed from fore- 
head to occiput for three or four minutes at a time. At the end oi ten 
days he had lost his diplopia, the pupil of the right eye had regained 
its natural diameter and irritability, and the vertigo and headache had 
notably diminished. The treatment was continued, and at the end of 
a month he had recovered the sensibility and power on the paralyzed 
side to such an extent, and had improved so much in other respects, 
that I advised him to take a short journey. He was absent two weeks, 
during which period he continued to take the pills as before, and on 
his return was, to all appearance, well. He has since remained in ex- 
cellent health. 

II. — Mr. R. W., a merchant of this city, consulted me in April, 1868, 
under the following circumstances : 

After a long period of great domestic anxiety, during which he had 
been engaged in some heavy commercial transactions, and had suffered 
from wakefulness, he experienced one afternoon, while riding in the 
park in his carriage, a slight quivering motion at the apex of the tongue. 
It continued until he reached home; and then, upon looking in a mir- 
ror, he could see the fibrillary movement very distinctly. He was not 
alarmed, and went to bed at his usual hour. In the morning he noticed 
a little thickness of speech, but the movement had ceased. That after- 
noon he had a violent headache, attended with vertigo and nausea. Be- 
coming alarmed, he sent for his family physician, who ascribed the 
symptoms to indigestion, and administered a mild cathartic. The fol- 
lowing day, on attempting to rise from the bed to go to the water- 
closet, he was attacked with such a severe vertigo that he was obliged 
to lie down again; and, though he did not for a moment lose conscious- 
ness, his faeces escaped from him involuntarily. From this time he 
gradually lost strength in both arms and legs, and his speech became 
very defective. His memory suffered to such an extent that he forgot 
the names of his children. There was very little headache, the vertigo 
had ceased, there was no disturbance of vision, and no loss of power 
over the sphincters. About six weeks after the occurrence of the first 
symptom noticed, he came under my care. 

At this time there was anaesthesia of both sides of the body, both 
legs and both arms had lost power; he clipped his words, and frequently 
substituted others of similar sound or meaning for those he ought to 
have used. His memory was much weakened, and there was a strong 
tendency to stupor. There were no troubles of the special senses — 
ophthalmoscopic examination revealed nothing abnormal — there was no 
facial paralysis. I diagnosticated softening of the brain from general 
cerebral anasmia consequent upon congestion and cerebral exhaustion, 



CEREBRAL SOFTENING. 179 

and I prescribed a liberal allowance of wine, a full and nutritious diet, 
carriage exercise, and amusements of various kinds. This was the very 
reverse of the treatment to which he had been subjected. In addition, 
I recommended the constant galvanic current, to be applied as in the 
previous case, and gave the following prescription: $. Olei phosphorat. 
1 ss; mucil. acacias, §j; ol. bergamii, gtt. xv. M. ft. emulsio. Dose, 
g*tt. xv. ter die. 

The treatment was carried out with the result of obtaining a gradual 
and permanent improvement, so that at the end of about six months 
the patient was well. He then went to Europe, where he now is, with 
as good health as he has ever enjoyed. 

Other cases, similar in their general features, have been under my 
care with a like result in each, and several others have been very decid- 
edly improved and relieved of the more prominent symptoms of the 
disease, without, however, regaining full health. The means of treat- 
ment thus far consist in the use of tonics, stimulants, and especially 
phosphorus and strychnine, the avoidance of all severe mental exertion, 
and all excessive emotion, open-air exercise, and the use of the constant 
galvanic current. 

The beneficial effects of maintaining the physical strength were 
several years since pointed out by Mr. F. Skey * in a clinical lect- 
ure delivered at St. Bartholomew's Hospital, but it must be con- 
fessed that the opposite plan of treatment has been very generally 
followed. 

Softening from the effects of thrombosis or embolism is, as I have 
said, not much under the control of the physician. Patients recover 
from it, however, when they are of good constitution, and when the 
focus of softening has not been extensive. The mind and body may, 
and in such cases generally do, remain feeble, and we are therefore 
consulted for the relief of the condition. In such cases tonics, and 
among them phosphorus, strychnine, and wine, occupy a prominent 
place; the constant galvanic current to the head, and the induced to 
the paralyzed muscles, will rarely fail to be of service. 

III. — Thus a gentleman, who had been a distinguished officer of the 
army, suffered from loss of memory, defective articulation, ptosis, double 
vision, and right hemiplegia, probably the result of embolism. Several 
years before he came under my charge, he had been treated by Dr. J. 
T. Metcalfe, for heart-disease, the result of acute rheumatism. I gave 
the phosphide of zinc and extract of nux-vomica according to the for- 
mula previously mentioned, advised a liberal use of wine and beef- 
steaks, applied the primary current to the brain, and the induced cur- 
rent to his paralyzed arm and leg, and in a few weeks had the satisfac- 
tion of seeing such a degree of improvement as almost to constitute a 

1 " On the Value of Tonic Treatment in some Diseases of the Brain, more especially 
Cases of Ramollissement," Dublin Hospital Gazette, November, 1858. 



180 DISEASES OF THE BRAIN. 

cure. The ocular troubles had disappeared, his memory had improved, 
he talked as well as ever, and the numbness and loss of strength were 
no longer remarked unless he over-exerted himself, which, owing to his 
general feeling of Men aise, he was very apt to do. He remained in 
this condition for over a year, when he had several other attacks of 
embolism, each of which left him more weak, mentally and physically, 
than before, and of which he eventually died. 

There were some interesting features connected with this case, 
which will be referred to at greater length under the head of 
aphasia. 

IV. — In another case, in which there was reason to think a foyer 
of softening had been absorbed, a marked relief from the sequelae was 
obtained. The patient, a literary gentleman of distinction, had, several 
years previously to my seeing him, suffered from an attack of acute 
rheumatism with endocarditis. About a month after his recovery, as 
he was sitting in his library before the fire, he felt a sensation as if one 
side of his face had suddenly become much heavier than the other. Al- 
most immediately afterward he lost consciousness, and fell to the floor. 
He could not have been in this condition longer than five minutes 
when he came to himself, to find that he was paralyzed in the right 
arm and leg. Attempting to call for assistance, he found he could 
not articulate. His wife soon afterward entered the room, and medical 
aid was obtained. He was bled to the extent of sixteen ounces, and 
purged with croton-oil. 

The following day he was much better; could move his arm and 
leg, and articulate with some degree of distinctness, but toward even- 
ing headache ensued, he became delirious, and the paralysis increased. 
Of the condition immediately following, he could give no very clear 
account. He only knew that he was confined to his bed for several 
weeks, was delirious part of the time, and that, after the acute attack 
passed off, he was left with an enfeebled mind, imperfect articulation, 
and paralysis of the arm and leg on the right side. He went to 
Europe, traveled extensively, and returned at the end of a year very 
much improved, but still with some degree of mental weakness, 
defective speech, and paralysis, remaining. 

When he came under my observation, the following were the prin- 
cipal symptoms observed: The strength of the right arm, as measured 
with the dynamometer, was not one-third that of the left; the exten- 
sors of the leg and foot were almost entirely paralyzed, so that in 
walking he abducted the leg so as to cause the foot to clear the 
ground ; electro-muscular contractility was much weakened, though 
the induced current caused feeble contractions. His speech was af- 
fected mainly as regarded the memory of words. He spoke with a 
good deal of volubility, but constantly used the wrong expressions. 
Thus, when he wished to tell me that he had visited Europe for the 



CEREBRAL SOFTENING. 181 

benefit of his health, he said : "I went to Elope for the bequest of my 
heoVe," and then went on — continually making other mistakes — to tell 
me a lono- story which I could scarcely understand. His emotions 
were easily disturbed: he cried because he had to wait a few minutes 
in my reception-room before seeing me. 

Ophthalmoscopic examination showed pale choroids and straight 
and attenuated retinal vessels. Auscultation revealed the existence 
of both mitral and aortic regurgitation. 

Taking into consideration the history of the case and the present 
condition of the patient, I diagnosticated embolism of the left middle 
cerebral artery, subsequent softening and eventual absorption of the 
diseased part of the brain. My idea was that the brain, as a whole, 
was anaemic, and that, with improved nutrition of it and the paralyzed 
limbs, amelioration of the symptoms was possible. 

I therefore prescribed the phosphide of zinc and nux-vomica pills 
as before mentioned, directed the use of wine to the extent of half a 
bottle of champagne daily, and advised that animal food should form 
the principal portion of each meal. Since his illness he had, by direc- 
tion of his physician, left off the use of coffee. I directed it to be 
resumed, and to be taken strong. The primary galvanic current was 
passed through the head in the manner previously indicated in this 
chapter, and the induced current was applied for half an hour three 
times a week to the arm and leg, each paralyzed muscle receiving a 
full share of attention. 

It was not long before signs of amendment were noticed. His 
strength became greater in the arm, and he was able to extend the leg 
and to raise the foot after half a dozen electrical applications. His 
speech next gave evidence of improvement, and his mind became 
stronger. The treatment was continued for about four months, with 
only an intermission of a week. x\t the end of that time his gait was 
almost natural, though he still swung the foot a very little, his arm 
was nearly as strong as the other, his mind was not perceptibly weaker 
than that of other persons of his age (fifty -five), and his speech was 
excellent except when he was excited and very anxious to express 
himself correctly and fluently. 

There is one point in regard to which a few words are perhaps 
necessary, and that is to enter a protest against the use of counter- 
irritation of any kind, and to discountenance, as far as I can, the em- 
ployment of the actual cautery. I have never seen the least advantage 
follow the application of croton-oil to the shaven scalp, nor can I con- 
ceive how such a measure can be recommended on rational grounds. 
I have several times witnessed its action, and have invariably seen it 
aggravate the symptoms. In the case of a gentleman from St. Louis, 
affected with cerebral softening, the effect was to make his speech 
still more imperfect and his mind weaker. A lady, who was affected 



182 DISEASES OF THE BRAIN. 

with all the more prominent symptoms of softening of the brain, fiad 
all the phenomena increased in violence after the application of the 
actual cautery to the nape of the neck. I could easily adduce otncr 
examples to the same effect, were it necessary. 



CHAPTER VII. 

APHASIA. 



The subject of aphasia is of such interest, and so much attention 
has recently been given to it by physiologists and pathologists, that, 
although it is only a symptom common to several morbid conditions, 
a treatise on diseases of the nervous system would scarcely be re- 
garded as complete without its being fully considered. 

By aphasia is understood a condition produced by an affection of 
the brain by which the idea of language, or of its expression, is im- 
paired. The word is derived from the Greek— a, privative, and cpaaig, 
speech — and, as stated by Trousseau, was proposed by M. Chrysaphis, 
a distinguished Greek scholar, as a substitute for alalia, used by Lor- 
dat, and aphemia, employed by Broca, to designate the same condition. 

In the definition which I have given of aphasia, the term is limited 
to impairment of the idea of language or of its expression. It does 
not, therefore, include those cases in which the individuals are able to 
speak, but will not ; such as are met with among the insane. The idea 
of language is as perfect as ever, and is doubtless entertained, but the 
person does not speak because he does not will to do so, and this fail- 
ure may arise either from a lack of the necessary power, or from a 
stubborn determination not to speak. A lady was a short time since 
under my charge who had been treated by a homoeopathic physician 
as a case of aphasia. A very slight examination was sufficient to con- 
vince me that the case was one of hysteria. She had not spoken for 
several months, but upon one occasion she came /to my office with her 
maid, whom she required to repeat the alphabet, and when the right 
letter was reached she signified the fact by raising her hand. She thus 
spelled out the words she wished to use. Subsequently she procured a 
card with all the letters on it, such as are used for children learning 
their alphabet, and she composed her words from this. Of course all 
these facts showed that her idea of language was intact, but she still 
might have lost the power of coordinating the muscles concerned in 
articulation so as to express herself in spoken words. Although I was 
sure this was not the case, I failed to make her speak, until one morn- 
ing she became very much interested in something I was saying, and, 
finding her alphabet too slow a means of expression, dropped it and 



APHASIA. 183 

began to speak with great fluency. After talking with energy for a 
quarter of an hour, she suddenly recollected herself and took up her 
card of letters again, but the charm was broken, and by degrees she 
resumed her speech. At one time this lady was under the care of my 
friend Prof. Flint, for some chest or throat difficulty, and on one occa- 
sion spoke very well. 

Neither does aphasia embrace cases of inability to speak from paral- 
ysis of the tongue or other muscles of articulation. Defective speech 
from this cause is frequently met with in hemiplegia, in glosso-labio- 
laryngeal paralysis, and some other affections. In such instances the 
idea of language remains, but the patient does not speak because he is 
unable to put the organs of articulation in motion. A few days ago a 
gentleman, a prominent merchant of the city, was sent to me as a case 
of aphasia. As he entered my consulting-room, I saw that he was 
hemiplegic on the left side, and, on telling him to put out his tongue, 
found that he could not get it beyond the teeth, or touch the roof of 
his mouth with it. The history of the case was that of ordinary cere- 
bral haemorrhage, and he regained the power of speaking after several 
applications of the primary and induced galvanic currents had been made 
to the tongue and muscles of the face. 

The distinction between aphonia and aphasia must also be made. In 
the one the idea of speech is undisturbed, and articulation is not inter- 
fered with except as regards phonation. Aphonic patients can whisper, 
but are unable to speak in full voice, owing to some laryngeal affection 
impairing the tone of the vocal chords. 

The fact that the faculty of speech may be deranged independently 
either of the will, paralysis, or loss of voice, appears to have been 
noticed at a very early period in the progress of science. Thus Isaiah * 
says, " For with stammering lips and another tongue will he speak to 
this people;" and again, 2 "Thou shalt not see a fierce people, a people 
.of a deeper speech than thou canst perceive; of a stammering tongue 
that thou canst not understand." 

Thucydides mentions that many, who suffered from the plague which 
raged at Athens, found on recovering that they had not only forgotten 
the names of their friends and relations, but also their own names. 

Pliny, 3 in the chapter entitled Memoriae, Exempla, sa} 7 's, in speak- 
ing of this faculty : "For nothing is so weak in man; disease, falls, 
injuries, even a fright, may impair it partially, or destroy it altogether. 
A blow from a stone has abolished the memory of the alphabet. A fall 
from a high roof has caused a man to cease to recognize his mother and 
neighbors, another even forgot his slaves, and Messala Corvinus, the 
orator, could not recall his own name." 4 

1 Chapter xxviii., 11. 2 Chapter xxxiii., 19. 8 Lib. vii., cap. xxiv. 

4 Trousseau has translated this passage somewhat differently. I quote from an illu- 
minated copy printed at Tarvisium (Treviso), in October, 1479. 



184 DISEASES OF THE BRAIN. 

Suetonius ' relates that Claudius so far lost his memory that he for- 
got the names of persons to whom he desired to speak, and could not 
even recollect the words he wished to use. 

Passing over several authors of later times who have recognized the 
existence of the difficulty in question, we come to Crichton, 8 who re- 
marks as follows: " There is a very singular defect in memory, of which 
I have myself seen two remarkable instances. It ought rather to be 
considered as a defect of that principle by which ideas and their proper 
expressions are associated, than of memory, for it consists in this, that 
the person, although he has a distinct notion of what he means to say, 
cannot produce the words which ought to characterize his thoughts. 
The first case of this kind which occurred to me in practice was that of 
an attorney much respected for his integrity and talents, but who had 
many sad failings to which our physical nature too often subjects us. 
Although nearly in his seventieth year, and married to an amiable lady 
much younger than himself, he kept a mistress, whom he was in the 
habit of visiting every evening. The arms of Yenus are not wielded 
with impunity at the age of seventy. He was suddenly seized with 
great prostration of strength, giddiness, f orgetfulness, insensibility to all 
concerns of life, and every symptom of approaching fatuity. His for- 
getfulness was of the kind alluded to. When he wished to ask for any 
thing, he constantly made use of some inappropriate term. Instead of 
asking for a piece of bread, he would probably ask for his boots ; but, 
if these were brought, he knew they did not correspond with the idea 
he had of the thing he wished to have, and was therefore angry. Yet 
he would still demand some of his boots and shoes, meaning bread. If 
he wanted a tumbler to drink out of, it was a thousand to one he did 
not call for a certain chamber-utensil, and, if it was the said utensil he 
wanted, he would call it a tumbler or a dish. He evidently was con- 
scious that he pronounced wrong words, for, when the proper expres- 
sions were spoken by another person, and he was asked if it were not 
such a thing he wanted, he always seemed aware of his mistake, and cor- 
rected himself by adopting the appropriate expression. This gentleman 
was cured of the complaint by large doses of valerian and other proper 
medicines." 

Dr. Crichton subsequently met with another case similar to the fore- 
going, and he quotes the following from Prof. Gruner, of Jena, in vol. 
vii. of the Psychological Magazine. The patient, a learned gentleman, 
after his recovery from an acute fever, suffered a loss of memory for 
words. Among the first things he desired to have was coffee (Jcaffee), 
but, instead of pronouncing the letter/*, he substituted in its place a z, 

1 " C. Suetonii Tranquilli," xii. Cassares. 

2 "An Inquiry into the Nat are and Origin of Mental Derangement, comprehending a 
Concise System of the Physiology and Pathology of the Human Mind, and a History of 
the Passions and their Effects," London, 1798, vol. i., p. 371. 



APHASIA. 185 

and therefore asked for a cat (Jcatze). In every word which had an /he 
committed a similar mistake, substituting a z for it. 

He also cites, from Van Goens, the case of Madame Hennert, wife 
of the professor of mathematics at Utrecht, who suffered a similar de- 
fect of memory. When she wished to ask for a chair she asked for a 
table, and when she wanted a book she demanded a glass. But, what 
was singular in her case was, that when the proper expression of her 
thought was mentioned to her, she could not pronounce it. 

She was angry if people brought her the thing she had named in- 
stead of the thing she desired. Sometimes she herself discovered that 
she had given a wrong name to her thoughts. This complaint continued 
several months, after which she gradually recovered the right use of her 
recollection. It was only in this particular point that her memory 
seemed to be defective, for M. Van Goens assures us that she con- 
ducted her household affairs with as much regularity as she ever had 
done, and that she used to show her husband the situation of the heavens 
on a map with as much accuracy as when she was in perfect health. 

The following case, in Gesner's Entdeckungen der JVeuesten Zeit in 
der Arzneigelehrheit, is likewise quoted by Crichton : 

" A man, aged seventy, was seized, about the beginning of January, 
with a kind of cramp in the muscles of the mouth, accompanied with a 
sense of tickling all over the surface of the body, as if ants were creep- 
ing over it. On the 20th of the same month, after having experienced 
an attack of giddiness and confusion of ideas, a remarkable alteration 
of his speech was observed to have taken place. He articulated easily 
and fluently, but made use of strange words, which nobody understood. 
The number of these does not at present seem to be great, but they are 
frequently repeated. Some of them he seems to forget entirely, and 
then new ones are formed. When he speaks quick he sometimes pro- 
nounces numbers, and now and then he employs common words in their 
proper sense. He is conscious that he speaks nonsense. What he 
writes is equally faulty with what he speaks. He cannot write his name. 
The words he writes are those he speaks, and they are always written 
conformably to his manner of pronouncing them. He cannot read, and 
yet many external objects seem to awaken in him the idea of their 
presence." 

Dr. Rush, 1 in the work the title of which is cited below, in chapter xii., 
which treats of Derangement in the Memory, refers so specifically to 
affections of the speech that I quote his language with some degree of 
fullness, and I do so with the less hesitation as his observations appear 
to have escaped notice, both in this country and in Europe. He says: 

" 1. There is an oblivion of names and vocables of all kinds. 

" 2. There is an oblivion of names and vocables, and a substitution 

1 " Medical Inquiries and Observations upon Diseases of the Mind." Fourth edition. 
Philadelphia, 1830, p. 274. The first edition was published in 1612. 



186 DISEASES OF THE BRAIN. 

of a word no ways related to them. Thus, I knew a gentleman afflicted 
with this disease, who, in calling for a knife, asked for a bushel of wheat. 

" 3. There is an oblivion of the names of substances in a vernaculal 
language, and a facility of calling them by their proper names in a dead 
or foreign language. Of this, Wepfer relates three instances. They 
were all Germans, and yet they called the objects around them only by 
Latin names. Dr. Johnson, when dying, forgot the words of the Lord's 
prayer in English, but attempted to repeat them in Latin. Delirious 
persons, from this disease of the memory, often address their physicians 
in Latin or in a foreign tongue. 

" 4. There is an oblivion of all foreign and acquired languages, and 
a recollection only of vernacular language. Dr. Scandella, an ingenious 
Italian, who visited this country a few years ago, was master of the 
Italian, French, and English languages. In the beginning of the yellow 
fever which terminated his life in the city of New York in the autumn 
of 1798, he spoke English only ; in the middle of his disease he spoke 
French only; but on the day of his death he spoke only in the language 
of his native country. 

" 5. There is an oblivion of the sound of words, but not of the let- 
ters which compose them. I have heard of a clergyman in Newburyport, 
who, in conversing with his neighbors, made it a practice to spell every 
word that he employed to convey his ideas to them. 

" 6. There is an oblivion of the mode of spelling the most familiar 
words. I once met with it as a premonitory symptom of palsy. It oc- 
curs in old people, and extends to an inability, in some instances, to 
remember any more of their names than their initial letters. I once saw 
a will subscribed in this way by a man in the eightieth year of his age, 
who during his life always wrote a neat and legible hand. 

"9. There is an oblivion of names and ideas, but not of numbers. 
We had a citizen of Philadelphia many years ago, who, in consequence 
of a slight paralytic disease, forgot the names of all his friends, but 
could designate them correctly by mentioning their ages, with which he 
had previously made himself acquainted." 

Dr. Rush remarks of these cases, that " there appears to be some- 
thing like a palsy of the mind, quoad these specific objects." 

Thus far there had been no attempt to define with precision the seat 
of the faculty of language, or even to establish its existence; but, in the 
early part of the nineteenth century, Dr. Gall, a German physician, an- 
nounced that such a faculty did exist, and that it was seated in those 
convolutions of the brain which rest upon the posterior part of the 
supra-orbital plate, and that a large development of the organ was indi- 
cated by prominence and depression of the eyes. He was first led to 
believe in the existence of such an organ by observing that some of the 
scholars with whom, as a young man, he had to compete, excelled him 



APHASIA. 187 

in the ability to learn by heart, and he noticed that those thus endowed 
with great memory for words possessed prominent eyes. From these 
circumstances, he was gradually carried on to the foundation of his 
phrenological system. 

In reality, however, Gall considered that there were two organs of 
language in each hemisphere — the one originating the idea of words, 
the other the talent for philology, and for acquiring the spirit of lan- 
guages. The former organ he describes as lying on the posterior half 
of the supra-orbital plate, as before mentioned. It gives a talent for 
learning and recollecting words, and persons possessing it large, recite 
long passages by heart after reading them once or twice. The other is 
placed on the middle of the supra-orbital plate, and when it is large the 
eyeball is not only rendered prominent but is depressed, causing the 
lower eyelid to assume the appearance of a bag or fold. Persons having 
this organ large have not only an excellent memory for words, but a 
particular talent for the study of languages, for criticism, and in gen- 
eral terms for all that has reference to literature. 

Dr. Spurzheim, however, admits but one organ, lying transversely 
on the posterior portion of the supra-orbital plate, and this view is ac- 
cepted by Combe and other distinguished phrenological authorities. 1 

In support of his theory that there is such an organ, Gall cites the 
case of a notary reported by Pinel. 2 The latter, in speaking of apo- 
plexy, says this affection may be limited in its action to the words which 
are used to express ideas. In the case mentioned, the patient forgot, 
after an attack of apoplexy, his own name, that of his wife, those of 
his children and friends, although there was not the least paralysis of 
his tongue. He no longer knew how to read or write, and yet his 
memory as regarded other things was unimpaired. 

Dr. Gall 3 refers also to the case of a soldier, sent to him by Baron 
Larrey, who was affected in a manner similar to that of the notary. It 
was not his tongue which was involved, for he was able to move it 
about in all directions, and to pronounce words, but he had lost the 
memory for words, although he recollected other things as well as ever. 

I shall presently have occasion to refer to a still more interesting 
case, reported by Larrey, and one which appears to have escaped the 
notice of all writers on the subject of aphasia. 

Spurzheim mentions the case of one Lereard, of Marseilles, who, 
n&ving received a blow from a foil on the eyebrow (which one is not 
stated), lost the memory of proper names entirely. He sometimes even 
forgot the names of his intimate friends, and even of his father. 

1 For a full account of the subject, the reader is referred to a "System of Phrenol* 
°gy>" by George Combe, Boston, 1834, or to " Phrenology," etc., by J. S. Spurzheim, 
Boston, 1833. 

2 " Traite medico-philosophique, sur 1' alienation mentale." Second edition. Paris, 
1809, p. 90. 3 " Physiologie du cerveau," vol. iv., p. 84. 



188 DISEASES OF THE BRAIN. 

Gall, therefore, located the organ of language in a limited part of 
the anterior lobe of each hemisphere; but he adduced very little evi- 
dence to support his opinion, and hence his views did not meet with 
any thing like general acceptance. A number of cases, however, re- 
ported by Lallemand, Rostan, and others, support it, while several ad- 
duced by the same authors are opposed to it. 

In 1825 Bouillaud, 1 who had collected a great number of cases of 
affections of the brain, was surprised to find how frequently the loss of 
speech coexisted with disease or injury of the anterior lobes. He also 
confirmed, what others before him had noticed, that the loss of the 
power of expressing ideas in articulate language was often the only evi- 
dence of a brain-affection. 

He made one very important step in advance, and his views on this 
particular point are adopted — and often without credit — by the majority 
of the present writers on aphasia; he divided the faculty of speech into 
two distinct categories of phenomena: 

1. The faculty of creating words as representatives of our ideas, and 
of recollecting them — internal speech. 

2. The power of coordinating the movements necessary for the ar 
ticulation of these words — external speech. 

This classification forms the basis of the division of aphasia into the 
two varieties, the amnesic and the ataxic. 

The cases which Bouillaud adduced in support of his theory were 
many of them in patients who exhibited no other symptoms than the 
loss of the power of articulate language. They preserved their intelli- 
gence, comprehended perfectly questions put to them, and knew the 
value of words; but, although there was no paralysis of either the 
tongue or the lips, they were unable to utter a word. At the post- 
mortem examination, the lesion was always found in the anterior lobes. 
Sixty-four cases formed the basis of his conclusions. A part was direct, 
and went to show that lesion of the anterior lobes was accompanied 
by derangement in the faculty of speech; the other part was indirect, 
and established the fact that, when the anterior lobes were not affected, 
the lesion being in some other region of the brain, the faculty of speech 
remained intact. 

Cruveilhier opposed Bouillaud's views, and, in a paper read at the 
Athenee de Medecine in the same year, brought forward seven cases of 
persons, some of whom had lost the faculty of speech, but who, on post- 
mortem examination, were found to have no disease of the anterior 
lobes; and others who had spoken, but in whom there were more or less 
profound changes in these parts. 

Subsequently Andral 2 reported the results of the analysis of thirty- 

1 "Traite de l'encephalite," Paris, 1825; and also, "Recherches cliniques, propres a 
demontrer que la perte de la parole correspond a la lesion des lobules anterieurs du eer- 
Veau," Archives de med. t 1825. 2 " Clinique medicale," tome ii., p. 135. 



APHASIA. 189 

seven cases of lesion of one or both anterior lobes. Of these, speech 
was abolished twenty-one times, and preserved sixteen times. Lalle- 
mand ' also opposed Bouillaud with several cases; but the latter rejoined 8 
with a fresh array of thirteen cases in support of his doctrine, and with 
many arguments against the validity of those brought against him. 
Longet 3 declares that Bouillaud appears to have refuted many of the 
objections of his adversaries, and to have demonstrated that some of 
their cases were badly interpreted. At the same time, while admitting 
that it is possible that different parts of the brain preside over different 
voluntary movements, he affirms that there is nothing positively estab- 
lished as regards the localization of the active principles of these move- 
ments. 

Subsequently, in other memoirs, Bouillaud brought forward addi- 
tional cases in support of his theory, making a total of one hundred and 
three, and offered a prize of five hundred francs to any one who would 
adduce an instance of profound lesion of the anterior lobes without 
troubles of speech. Many years subsequently Velpeau announced that 
he should claim this prize, for that, in March, 1843, he had related the 
case, and presented the brain, of a wig-maker who had come under his 
care for prostatic disease. This man was in full possession of his 
reasoning faculties, and, moreover, was noted for his unconquerable 
loquacity. He died a few days subsequently, and on post-mortem ex- 
amination a scirrhous tumor was found to have entirely taken the 
place of the two anterior lobes of the brain. Very little faith seems to 
have been put by physiologists or pathologists in the history of this 
case. If it proves any thing, it is that the anterior lobes are useless 
appendages to the rest of the cerebral system. 

But Bouillaud was not content with the deductions to be drawn 
from pathology. In a series of experiments, he endeavored to establish 
the truth of his idea, and thus bring the science of physiology to his 
support. These experiments were detailed in a paper 4 read before the 
Academy of Sciences, in September, 1827, which was subsequently 
(1830) published in the tenth volume of Magendie's Journal de Physi- 
ologie, from which I quote. 

The experiments relative to the anterior lobes were made on dogs. 
Only one was entirely successful — the animals in the others dying too 
soon after to admit of satisfactory deductions being made. But the 
twentieth experiment was more satisfactory. 

On the 28th of June, 1826, he passed a gimlet through the anterior 

1 Op. cit., lettres 6, 7, 8. 

3 " Exposition de nouveaux faits a l'appui de ropinion qui localise dans les lobes an- 
teneurs du cerveau le principe legislateur de la parole." " Bulletin de l'Academie de 
Medecine," 1839, tome iv., p. 282. ' 

3 " Traite de la physiologie," tome ii., p. 438. 

• " Recherches experimentales sur les fonctions du cerveau (lobes cerebraux) en gen& 
n*l et sur celles de sa portion ante>ieure en particulier." 



190 DISEASES OF THE BRAIN. 

part of the brain of an active, docile, and intelligent dog. Immediately 
afterward the animal was convulsed, and could not rise from the ground. 
Sight and hearing remained. Symptoms of compression soon came on ; 
the result, probably, of the haemorrhage. Eventually, the animal re- 
covered, but it was found to have lost much of its intelligence and 
agility. The faculty of memory seemed to have been entirely abolished, 
and there was a decided expression of imbecility in its countenance. It 
could no longer ascend or descend a staircase; the fore-legs were lifted 
very high in walking, and its movements were all badly coordinated. 
XT ' 7 hen struck or made to walk, it uttered sharp cries, but it had lost 
entirely the ability to bark. As Bouillaud remarks, "it no longer 
barked, either to show its affection, or to drive away strangers who 
came to the house." Once only, on the 18th of July, it tried to bark at 
a passer-by, but failed in the attempt. 

This is the only experiment I have been able to find which has any 
bearing upon the question of the localization of the faculty of language. 
And I do not quote it as proving much on the subject. The difficulties 
in the way of experimentation are almost insuperable, to say nothing of 
the fact that it is doubtful if any of the sounds made by animals can be 
compared with human speech. 

But unintentional experiments have been performed upon the 
human subject, which tend to show that, though the faculty of lan- 
guage may be located in one or both anterior lobes, either may be 
seriously injured without the faculty of language suffering to any ap- 
preciable extent. Two of them have happened in this country, and, 
although referred to in connection with aphasia by Seguin and Harris, 
I take satisfaction in bringing them forward on account of their great 
importance to the question under consideration. 

The first is related by Dr. Harlow, 1 of Vermont: 

The subject was a strong, healthy man, twenty-five years of age, 
and was engaged in ramming down a charge of powder in a rock to be 
blasted, when an explosion took place, and the tamping-iron was driven 
clear through his head. 

In a few minutes he recovered his consciousness, was put into a cart 
and carried three-quarters of a mile to his residence, where he got out 
and walked into the house. Two hours afterward he was seen by Dr. 
Harlow. He was then quite conscious and collected in his mind, but 
exhausted by extensive haemorrhage from the hole in the top of his 
head. Blood, pus, and particles of brain, continued to be discharged 
for several days, but by January 1, 1849, the wound was quite closed 
and his recovery complete. There was no pain in the head, but a queer 
feeling, which he could not describe. As regarded his mind, he was 
fitful and vacillating, though obstinate, as he had always been. He 

1 Boston Medical and Surgical Journal, December, 1849, vol xxxix., p. 389. Also, 
"Descriptive Catalogue of the Warren Anatomical Museum,'' Boston, 1870, p. 145. 



APHASIA. 191 

Decame very profane, never having been so before the accident. He 
lived til] May 21, 1861, twelve and a half years subsequent to the acci- 
dent, when he died, after having had several convulsions. His cranium 
was obtained, and, with the bar, is now preserved in the Warren Ana- 
tomical Museum at Boston. Dr. J. B. S. Jackson * thus describes the 
skull: 

" The whole of the small wing of the sphenoid bone upon the left 
side is gone, with a large portion of the large wing, and a large por- 
tion of the orbital process of the frontal bone, leaving an opening in 
the base of the skull two inches in length, one inch in width poste- 
riorly, and tapering gradually and irregularly to a point anteriorly. 
This opening extends from the sphenoidal fissure to the situation of the 
frontal sinus, and its centre is an inch from the median line. The optic 
foramen and the foramen rotundum are intact. Below the base of the 
skull the whole posterior portion of the upper maxillary bone is gone. 
The malar bone is uninjured ; but it has been very perceptibly forced 
outward, and the external surface inclines somewhat outward from 
above downward. The lower jaw is also uninjured. The opening in 
the base, above described, is continuous with a line of old and united 
fracture that extends through the supra-orbitary ridge in the situation 
of the foramen, inclines toward and then from the median line, and 
terminates in an extensive fracture that was caused by the bar as it 
came out through the top of the head. This fracture is situated in the 
left half of the frontal bone, but inferiorly it extends somewhat over the 
median line. In form it is about quadrilateral; but it measures two and 
a half by one and three-quarter inches. Two large pieces of bone are 
seen to have been detached and upraised, the upper one having been 
separated at the coronal suture from the parietal bone, and being so 
closely united that the fracture does not show upon the outer surface. 
The lower piece shows the line of fracture all around. Owing to the 
loss of bone, two openings are left in the skull; one that separates the 
two fragments has nearly a triangular form, extends rather across the 
median line, and is four inches in circumference ; the other, situated 
between the lower fragment and the left half of the frontal bone, is long 
and irregularly narrow, and is two and five-eighths inches in circum- 
ference. The edges of the fractured bones are smooth, and there is 
nowhere any new deposit." 

From this account it will be seen that the left anterior lobe of the 
brain suffered severely by this terrible injury, and yet it is not stated 
that the subject had ever shown any difficulties of speech. If the 
faculty of language resides in the whole of the lobe, such an immunity 
could scarcely have existed, It must be noted, however, and the photo- 
graph of the cranium establishes the fact, that the third frontal convo- 
lution and the island of Reil escaped all injury. Another interesting 

1 " Descriptive Catalogue of Warren Anatomical Museum," loc. cit. 



192 DISEASES OF THE BRAIN. 

circumstance is the addiction to profanity after the accident. A like 
phenomenon has been noticed in cases of aphasia. 

The second instance is almost as extraordinary. I quote the history 
of the case, 952, from Dr. Jackson : * 

" Cast of the head of a man who was transfixed through the head by 
an iron gas-pipe, and who, to a very considerable extent, recovered from 
the accident. 

"The patient, a healthy and intelligent man, about twenty-seven 
years of age, was blasting coal when the charge exploded unexpectedly, 
and the pipe was driven through his head, entering at the junction of 
the middle and outer thirds of the right supra-orbitary ridge, and emerg- 
ing near the junction of the left parietal, occipital, and temporal bones. 
One of his fellow-miners saw him upon his hands and knees, and strug- 
gling as if to rise ; and, going to his assistance, he placed his knee up- 
on his chest, supported his head with one hand and with the other with- 
drew the pipe. This last projected about equally from the front and 
back of the head, and much force was required for its withdrawal." 

Brain escaped from the anterior opening, and coma and collapse 
supervened. " In seven weeks he sat up, and in one more walked about. 
The right hand he used somewhat, but less well than the left. For 
about ten months after the accident his memory for some things was 
nearly lost, but during the next two months there was a considerable 
improvement." 

The accident happened on May 14, 1867, and in June, 1868, the 
patient, with the gas-pipe, was exhibited to the Massachusetts Medical 
Society. "The man appeared to be in a good state of general health; 
and, though his mental powers were considerably impaired, there was 
nothing unusual in his expression, nor would there be noticed, in a few 
minutes' conversation with him, any marked deficiency of intellect." 

It is very evident that in this case the right anterior lobe was 
seriously injured — the left escaping — and yet there does not appear to 
have been any aberration of speech. It is to be regretted, however, 
that the history is not more specific as to the things in regard to which 
the memory was deficient. 

There are other cases which militate against Bouillaud's doctrine. 
Thus, M. Peter 2 states that a drunken cavalry-soldier fell from his horse 
on the back of his head, and fractured his skull. Stupor set in at once, 
followed by the most violent delirium. The man kept constantly shout- 
ing the worst possible oaths, and held connected conversation with im- 
aginary persons. He died at the end of thirty-six hours, without hav- 
ing recovered his reason. On dissection, a fracture of the roof and base 
of the skull was discovered in all its length. The posterior lobes of the 

1 Op. cit., p. 149. 

8 Quoted by Trousseau, " Lectures on Clinical Medicine." Translated by Bazire, vol. 
L, p. 256. 



APHASIA. 193 

brain were found, on post-mortem examination, to have sustained no 
injury, but both anterior lobes were in a pulpy condition, through a 
most violent contusion, caused by their being knocked against the an- 
terior wall of the cranium. The whole thickness of the lobes was dis- 
organized. As Trousseau remarks, this case shows that the two frontal 
lobes may be destroyed in their anterior portion without causing a loss 
of the faculty of speech. Trousseau also cites the case of two officers, 
who, after a quarrel, fought a duel. One of them fired first, and the 
ball entered his adversary's head at one temple, passed through the 
brain, and then raised the temporal bone on the opposite side. The 
ball was extracted, and the patient immediately made a sign with his 
hands, and expressed his thanks in a very low voice. He recovered, for 
the time being, and, during five months thereafter, could speak perfect- 
ly well, and was remarkable for the wit and fluency of his conversation 
and writing. He subsequently died of softening; and it was found, on 
post-mortem examination, that the ball had passed through the two 
frontal lobes in their middle portion. A still more striking case is re- 
ferred to by Dr. Bazire, in a note to Trousseau's lecture on aphasia, in 
the work cited. It was reported in 1843 by M. Aug. Berard, to the 
Anatomical Society of Paris. The patient, a miner, was knocked down 
and severely injured by an explosion in a mine. He did not lose con- 
sciousness, but managed to creep out of his hole and to call to his help 
some men who were working a short distance off. He begged them to 
fetch a cart and to take him to M. Berard's house. He was there ex- 
amined. The whole frontal region was laid open, the integuments hung 
in shreds, the bones were splintered and in detached fragments, and the 
brain was exposed. Both anterior cerebral lobes were completely de- 
stroyed, and in their stead was a mixture of blood, of bony splinters, 
and brain-substance. In spite of this frightful injury, the man could 
relate in all its details how the accident had occurred. He died the 
next day. 

Whether or not we accept this case in all the import claimed for it, 
there can be no doubt that Bouillaud is wrong in claiming that injury 
of the anterior lobes is necessarily followed by some derangement in the 
faculty of speech. It is only fair, however, to state that latterly he has 
admitted that the organ of language may occupy the posterior part of 
either lobe. 

Dr. M. Dax, in 1836, read a paper before the medical congress which 
met that year at Montpellier, in which he came to the conclusion that 
the faculty of language " was seated, not as Gall and Bouillaud had 
contended, in both anterior lobes of the brain, but that it occupied only 
the left anterior lobe." He based this opinion on one hundred and 
forty cases of aphasia attended with paralysis, and in which the loss of 
power was on the right side; showing, therefore, that the lesion which 
produced the aberration of speech also caused the hemiplegia, and that 
14 



194 DISEASES OF THE BRAIN. 

this lesion must have been on the left side. This paper at the time at- 
tracted very little attention, and was forgotten till the year 1861 wit- 
nessed the reopening of the discussion. 1 

It would be very easy to quote a large number of cases confirmatory 
of Dr. Dax's doctrine, but a few will suffice to show the general bearing 
of a great many others. The following case seems to have escaped 
notice. It is not the one referred to by Gall as being sent to him b} 
Larrey. In that case the left anterior lobe was injured and there wai 
aphasia, but the lesion was caused by a sword. 

Baron Larrey 2 presented to the Academy the cranium of a subject 
with the following history: 

Toward the end of the year 1815 an officer of dragoons came to the 
hospital with a wound from a ball which he had received at Waterloo. 
The missile had entered the left side of the cranium at a point about 
six or eight millimetres from the eyebrow and near the temporal ridge. 
At first he had suffered loss of consciousness and profuse haemorrhage, 
but had recovered, with but slight loss of motor power. So far as his 
mind was concerned, there was no derangement except as regarded the 
faculty of speech; he had lost the memory of substantives. For this 
reason he was unable to drill his company, and, though able to distin- 
guish his men by their size, their form, their complexion, or their voice, 
he could not call them by name. He refused to allow the operation of 
trephining to be performed, and in 1827 died of phthisis. 

A post-mortem examination was made. The ball was found em- 
bedded in the thickness of the bone, having elevated and fractured the 
internal table. The dura mater was strongly adherent to the whole of 
the left anterior cranial fossa ; it was also thicker and denser than in the 
natural state. A spheroidal excavation, five centimetres in its horizontal 
and seven or eight in its vertical diameter, was discovered at the summit 
and on the temporal side of the left anterior lobe of the brain. 

Mr. Thomas Hood 3 reported the history of a patient, a sober, intel- 
ligent man, sixty years of agej who, on the evening of September 2, 
1822, suddenly began to speak incoherently, and became quite unintelli- 
gible to those around him. It was discovered tljat he had forgotten the 
name of every object in Nature. His recollection of things seemed to 
be unimpaired, but the names by which men and things were known 
were entirely obliterated from his mind, or rather he had lost the faculty 
by which they were called up at the control of the will. He was by no 
means inattentive, however, to what was going on, and he recognized 

1 Dr. Marc Dax's memoir was republished in the Gazette hebdomadaire, No. 17, April, 
1865. 

2 " Blessure du cerveau avec perte de memoire des noms substantives," Journal dc 
physiologie de Magendie, tome viii., 1828, p. 1. 

3 "Phrenological Transactions." Quoted by George Combe in his "System of Phre- 
nology," Boston, 1834, p. 429. 



APHASIA. 195 

friends and acquaintances perhaps as quickly as on any former occasion; 
but their names, or even his own or his wife's name, or the names of any 
of his domestics, appeared to have no place in his recollection. 

" On the morning of the 4th of September," says Mr. Hood, " much 
against the wishes of his family, he put on his clothes and went out to 
the workshop, and when I made my visit he gave me to understand, by 
a variety of signs, that he was perfectly well in every respect, with the 
exception of some slight sensations referable to the eyes and eyebrows. 
I prevailed on him with some difficulty to submit to the reapplication of 
leeches, and to allow a blister to be placed over the left temple. He 
was now so well in bodily health that he would not be confined to the 
house, and his judgment, in so far as I could form an estimate of it, was 
unimpaired, but his memory of words was so much a blank, that the 
monosyllables of affirmation and negation seemed to be the only two 
words in the language the use and significance of which he never en- 
tirely forgot. He comprehended distinctly every word which was spoken 
or addressed to him; and, though he had ideas adequate to form a full 
reply, the words by which these ideas are expressed seemed to have 
been entirely obliterated from his mind. By way of experiment I would 
sometimes mention to him the name of a person or thing, his own name 
for example, or the name of some one of his domestics, when he would 
repeat it after me distinctly once or twice ; but generally before he could 
do so a third time the word was gone from him as completely as if he 
had never heard it pronounced. When any person read to him from a 
book, he had no difficulty in perceiving the meaning of the passage, but 
he could not himself then read, and the reason seemed to be that he had 
forgotten the elements of written language, viz., the names of the let- 
ters of the alphabet. In the course of a short time he became very ex- 
pert in the use of signs, and his convalescence was marked by his im- 
perceptibly acquiring some general terms which were with him, at first, 
of very extensive and varied application. . In the progress of his recov- 
ery, time and space came both under the general application of time. 
All future events and objects before him were, as he expressed it, ' next 
time ; ' but past events and objects behind him were designated ' last 
time.'' One day, being asked his age, he made me to understand that 
he could not tell; but, pointing to his wife, uttered the words, ' many 
times ' repeatedly, as much as to say that he had often told her his age. 
When she answered sixty, he answered in the affirmative." 

On the 10th of January he suddenly became paralytic on the left 
side [this is evidently a typographical error for right side]. On the 17th 
of August he had an attack of apoplexy, and on the 21st he expired. 
In the Phrenological Journal, vol. iii., p. 28, Mr. Hood has reported 
the dissection of his brain: " In the left hemisphere, lesion of the parts 
was found, which terminated at half an inch from the surface of the 
brain, where it rests on the middle of the supra-orbital plate." Two 



196 DISEASES OF THE BRAIN. 

Bmall depressions or cysts were found in the substance of the brain, 
" and the cavity considered as a whole expanded from the anterior part 
of the brain till it opened into the ventricle in the form of a trumpet. 
The right hemisphere did not present any remarkable appearance." 

Dr. Thomas Hun, 1 of Albany, in detailing a case of amnesia in 
which there were no symptoms of paralysis, and in which there was 
no post-mortem examination, cites the case of a lady who died of cancer 
of the brain, occupying, at the time of her death, the greater portion 
of the left anterior lobe. In the early stages of her disease she was 
often unable to call the most familiar objects by name, and had to ex- 
press herself by signs or by pointing at the object. When the word 
she wanted was pronounced before her, she recognized it, and was able 
to repeat it. 

Other cases, and especially several which have occurred in my own 
experience, are reserved for future consideration. 

Up to this period we have the organ of articulate language limited 
to the left anterior lobe of the brain, but in 1861 its location was still 
further restricted. In that year M. Gratiolet, in discussing before the 
Anthropological Society of Paris a question relative to the comparative 
development of the brain and mind among different races, brought up 
the subject of cerebral localization, to which he announced himself as 
being strongly opposed. M. Auburtin, on the contrary, contended that 
the localization of the faculty of speech at least was definitely estab- 
lished, through the researches of Bouillaud, in the anterior lobes. In 
support of this view, he adduced cases which had already been brough 
forward, and cited others in addition, which went to show that loss of 
speech was the consequence of traumatic lesion of these parts of the 
brain. His adversaries cited other cases in which persons had preserved 
the faculty of language notwithstanding extensive lesions of the an- 
terior lobes. M. Auburtin responded that, if such profound and exten- 
sive injuries had not interfered with speech, it was because that part of 
the lobes in which the organ is situated was not involved. And he then 
cited the case of a patient in the Hospital for Incurables, who for many 
years had been deprived of the power of speech, and he declared that 
he would renounce the doctrine of Bouillaud if the autopsy of this 
patient did not reveal disease of the anterior lobes. The patient in 
question was under the charge of M. Broca, and the latter, a decided 
opponent, accepted the challenge of M. Auburtin, and declared that, 
when the man died, the examination should be made. 

Some time afterward the patient died, the post-mortem examination 
vvas made, and the lesion was found to occupy the left anterior lobe. 2 

From this time forward, M. Broca, who had been a most determined 

1 American Journal of Insanity, vol. vii., 1850-51, p. 359. 

2 See " Etude sur la localisation de la faculte du langage artieule." These de Paris 
ae ¥. Carrier, 186V. 



APHASIA. 197 

opponent of Bouillaud's views of localization, became converted, and 
carried them to a still more extreme point than even M. Marc Dax had 
done. Taking, as his principal case, the one to which M. Auburtin had 
pinned his faith, he read, in 1861, before the Anatomical Society of 
Paris, a memoir, 1 in which he discusses the question of the location of 
the faculty in question with all his perspicuity and directness. As the 
two cases cited by him are of historical interest, I give the chief details 
of them: 

A man named Le Borgne, who had been an inmate of another de- 
partment of Bicetre for over twenty years, was transferred to one of 
the wards under M. Broca's care, to be treated for a severe attack of 
phlegmonous erysipelas. The man was a confirmed epileptic, and had 
not spoken, since his entrance into the hospital, more than a few words, 
which he employed for the expression of all his ideas. It is stated that 
in other respects his intelligence was good. Le Borgne was known in 
the hospital by the name of " Tan," a word which he habitually used, 
and which, with the oath, " Sac?*6 nom de Dieu" constituted his entire 
vocabulary. " Tan," owing to the constancy with which he used it, was 
the name by which he was known in the hospital; and, when he could 
not make himself understood by his signs, he employed the oath, and 
gave other manifestations of anger. 

For several years he had remained in the hospital with no other 
lesion than that of speech, with an occasional epileptic paroxysm; but, 
after a few years, his right arm became paralyzed, and four years sub- 
sequently the leg of the same side was involved; his sight was likewise 
enfeebled, and for the past seven years he had been entirely confined 
to his bed. 

Notwithstanding the fact that he was almost in a dying condition 
when M. Broca first saw him, some important points in his cerebral 
difficulty were noted. To any question put to him, he replied, as usual, 
" Tan" but at the same time endeavored to make himself understood 
by signs. Thus he raised six fingers to indicate that six days had 
elapsed since the inception of his erysipelas, and by opening and shut- 
ting his hand four times and then raising one finger signified that he 
had been twenty-one years in Bicetre. 

Sensibility was lessened on the affected side; there was no deviation 
of the tongue, which could be moved freely in all directions, and no 
paralysis of the face beyond a slight weakness shown by the swelling of 
the left side when he breathed; there was a little difficulty of swallow- 
ing, from the fact that the muscles of the pharynx were gradually be- 
coming implicated. After a few days the man died. 

As I have said, the autopsy showed that the lesion was situated in 
the left anterior lobe. More exactly, however, it should now be stated 

1 " Sur le siege de la faculte de langage articule avec deux observations d'aphemie." 
Bulletin de la society anatomique, tome iv., 1861. 



19S DISEASES OF THE BRAIN. 

that it involved the inferior marginal convolution of the tempore* 
sphenoidal lobe, the convolutions of the island of Reil, and in the fron- 
tal lobe, the frontal transverse convolution, and the posterior half of 
the second and third frontal convolutions. The left corpus striatum 
was also affected. According to Broca, the disease had in all probabil- 
ity begun in the third frontal convolution, and had gradually extended T 
to the other parts; the paralysis marking the implication of the island 
of Reil and the corpus striatum. 

The other case was that of a man named Le Long, aged eighty-four 
years, who had entered the hospital for a fracture of the neck of the 
femur. Eighteen months before, he had been treated in the medical 
service for a temporary apoplexy, which had deprived him of the faculty 
of speech, but had caused no paralysis. Le Long, whose intelligence, 
facial expression, and ability to gesticulate, were very striking, made 
himself perfectly well understood, although able to pronounce indistinct- 
ly a very few words, but which were nevertheless properly applied. 
These words were " oui" " non, toujoyrs, tois " for trois, and Lelo for 
Le Long. Thus when asked, " Can you write ? " he answered, " Oui." 
" Have you any children ? " " Oui." " How many ? " " Tois," but at the 
same time, as if aware that he was not answering correctly, he raised 
four fingers. " How many boys ? " "Tois," raising two fingers. " How 
many girls ? " " Tois," holding up two fingers. " What time is it by this 
watch ? " " Tois," at the same time raising ten fingers to signify that 
it was ten o'clock. " How old are you ? " To this question he replied 
by two gestures ; the one consisting of raising eight fingers, the other 
of four fingers, by which he meant that he was eighty-four years old. 

Aside from this application of the word tois to all numbers, his 
answers were perfectly correct. The tongue was neither paralyzed nor 
thickened; on one side the larynx was mobile, and his limbs possessed 
their normal power for his age. It was therefore a case of pure aphasia, 
or, as Broca then designated the affection, aphemia. 

Twelve days after the accident, the patient died. The post-mortem 
examination revealed the existence of lesions, almost identical in situa- 
tion with those of the former case. The posterior part of the third left 
frontal convolution, and the contiguous part of the second, had been 
absorbed and replaced by a serous fluid. Two cases can scarcely decide 
any point in pathology; but, without venturing to assert positively that 
the organ of language resides exclusively in the posterior part of the 
third frontal convolution, M. Broca expressed the opinion that the in- 
tegrity of this convolution, and perhaps of the second, is indispensable 
to the normal operation of the function of speech. 

Many cases were adduced by Charcot, 1 by Falret, 2 by Perroud of 

1 Gazette hebdomadaire, 1863, pp. 473, 525. 

2 Archives de medecine, tome iv., Mars et Mai, 1864. 

8 Journal de medecine de Lyon, Janvier et Fevrier. 18G4. 



APHASIA. 199 

Lyons, by Trousseau, 1 and others, in support of the localization of the 
faculty of articulate language in the left side of the brain. Most of 
these cases were accompanied by right hemiplegia, and, in several, post- 
mortem examinations showed the lesion to exist in the parts designated 
by Broca. 

In the early part of 1833, M. G. Dax, son of the M. Dax who had 
placed the organ of language in the left hemisphere, presented, through 
AI. Lelut, a memoir to the Academy, in which he claimed with his father 
that aphasia was always the result of lesion of the left hemisphere, but 
he assigned a still more restricted position, by limiting it to the anterior 
and exterior part of the middle lobe. He cited forty cases of loss of 
the power of speech, coincident with lesion of the left hemisphere. 

Now, besides these direct cases, there are others which bear with 
almost as much effect on the affirmative of the doctrine in question, 
Thus M. Fernet, in 1863, presented a case to the Society de Biologie, in 
which there was left hemiplegia, but no aphasia. After death, soften- 
ing of the right hemisphere, from thrombosis of the right middle cere- 
bral artery, was found to exist. M. Parrot 2 adduced another case in 
which there was complete atrophy of the island of Reil, and of the third 
convolution of the right side, but in which there was no trouble of 
speech. These cases go to show that the organ of articulate language 
is not situated in the right hemisphere. 

M. Lesur 3 has reported a case which is of very great interest. A 
child was kicked on the head by a horse, and a fracture of the frontal 
bone was thus produced. The operation of trephining was performed 
at a point about an inch and a quarter above the left eye. After the 
operation and during the progress of the case, it was observed that, 
whenever pressure was made upon the brain through the hole in the 
cranium, the child lost the power of speech, and that when this pressure 
was removed she regained it. A similar case occurred several years ago 
in my own practice. 

Among British writers, Dr. Hughlings Jackson nas given the histo- 
ries of thirty-four cases of loss of speech coinciding with right hemiple- 
gia. He is entitled to the credit of making a beautiful application of 
anatomy and physiology to the pathology of the subject under considera- 
tion. The part of the brain designated by Broca as the seat of the 
organ of articulate language is nourished by the left middle cerebral 
artery. An obstruction of this artery would of course interfere with 
the perfect action of that region, and thus aberrations of speech would 
be produced. But the same artery also supplies blood to the corpus 
striatum of the same side. Hence the frequency with which aphasia is 
associated with right hemiplegia. The cause of the obstruction is gener- 
ally, according to Dr. Jackson, embolism, for in twenty of his cases the 

: Clinique medicate. 2 Gazette hebdomadaire, 1863, p. 506. 

3 Gazette des hopitaux, 4 " London Hospital RoporU," vol. L 



200 DISEASES OF THE BRAIN. 

heart was more or less affected, and in thirteen of them there was valvu 
lar disease. 

Among other British writers, some of whom will be more fully re- 
ferred to hereafter, must be mentioned, Dr. Sanders, 1 Dr. Moxon, 2 Dr. 
Ogle, 3 Dr. Bateman, 4 and Dr. Bastian. 6 

The matter does not appear to have attracted much attention from 
German physiologists and pathologists, since the discussion in the 
French Academy in 1861. Previous to that period several excellent 
memoirs upon the physiology of speech were published by Germans, 
among which that of Dr. Bergman 6 is preeminent. A memoir by Nasse 7 
is also interesting. 

In 1865 Von Benedict and Braunwart 8 published a very thorough 
paper on the subject, and other observers have reported cases. 

In this country there have been several very excellent memoirs upon 
aphasia, and, as we have already seen, the subject early attracted atten- 
tion, and the fact that such a condition could exist without other mani- 
fest symptoms was fully recognized. Thus Prof. A. Flint 9 detailed the 
histories of six cases, in one of which post-mortem examination showed 
extensive disease of the left anterior lobe, and in four, in which the 
situation of the hemiplegia was noted, the right was the affected side. 

Dr. H. B. Wilbur, 10 in a memoir on aphasia, treats of the aberrations 
of the faculty of language as they existed in certain idiots under his 
observation. His cases, though interesting, are scarcely in point, as the 
difficulties of speech were clearly the result of mental deficiencies. 

A very important memoir is that of Dr. E. 0. Seguin, 11 in which a 
very excellent history of the subject is given, with the citation of forty- 
eight cases from the records of the New York Hospital, in which there 
were difficulties of speech coexisting with hemiplegia, and two in which 
there was no hemiplegia. In several of these cases, however, as Dr. 
Seguin states, the loss of the faculty of speech was due to paralysis of 
the tongue and other muscles concerned in articulation. 

Another excellent paper is by Dr. T. W. Fisher, 12 of Boston. Dr. 
Fisher has studied the subject very philosophically, and records thirty- 

1 Edinburgh Medical Journal, August, 1866. 

2 British and Foreign Medico- Chirurgical Review, April, 1866. 

3 "St. George's Hospital Reports," vol. ii., 1867. 

* Journal of Mental Science, January, 1868, and subsequent numbers. 

5 British and Foreign Medico-Chirurgical Review, January and April, 1869. 

6 "Einige Bemerkungen iiber Storungen des Gedachtniss imd der Sprache. Ally* 
■ndne Zeitschrift fur Fsychiatrie, 1849, s. 657. 

7 A.llgemeine Zeitschrift u. s. w., 1853, s. 523. 

8 Canstatt's " Jahresbericht," 1865, s. 31. 

9 Medical Record (New York), March 1, 1866. 

10 American Journal of Insanity, July, 1867. 

11 Quarterly Journal of Psychological Medicine, etc., January, 1868. 

12 Boston Medical and Surgical Journal, September 1, 1870, and subsequent numbers. 



APHASIA. 201 

ei«*ht cases in which post-mortem examinations were made with defi- 
nite results. Cases have also been published by Bartholow 1 and 
others. 

With this outline statement of the history of the subject of 
aohasia, we are in a position to inquire more fully into the evi- 
dence which locates the organ of language in a particular region of 
the brain. 

Aphasia, as it is now understood, comprises several distinct vari- 
eties. At the time Wernicke's 2 scientific work appeared, aphasia 
was classified as either ataxic or as amnesic. But Wernicke's care- 
ful study of the subject led him to discard these terms and to sub- 
stitute in their place the terms motor aphasia and sensory aphasia. 
KtLssmaul 3 shortly afterward made a further advance by separat- 
ing sensory aphasia into its two component parts, word-deafness and 
word-blindness. In addition to motor aphasia, word-deafness, and 
word-blindness, we also recognize agraphia, paraphasia, amnesia, and 
apraxia. 

Each one of these forms will now be considered in detail. 

Motor aphasia consists of the loss of the memory of how to make 
the muscular movements of the lips and tongue necessary for the 
articulation of words. 

When this form of aphasia exists alone, the power of voluntary 
speech is abolished, and also the power of repeating words that are 
heard. There is no difficulty in comprehending written or printed 
letters or words, or of understanding words that are heard. The 
individual has simply forgotten how to place his tongue and lips in 
the proper positions for producing articulate speech, but can readily 
express his ideas by signs, by selecting the proper letters from an 
alphabet to spell out words, and also by writing, if the lesion is not 
cortical, and if the muscles of the arm are not too paretic. 

Word- deafness consists of the loss of the memory of the sound 
of words. To a person affected with word-deafness his own lan- 
guage sounds to him like a tongue with which he is totally un- 
familiar. He hears, but does not comprehend the meaning of the 
sounds. 

Word-deafness must not be confounded with word-amnesia. In 
the latter case the word is forgotten, but is immediately recognized as 
soon as it is heard, w T hile in word-deafness it is not understood at 
all. Word-deafness and auditory amnesia usually accompany each 
other. 

Word-blindness is the loss of the memory of the appearance of 
words. As the form of the letters and of the words arouses no rec- 

1 Medical Repertory, Cincinnati, January, 1869. 

2 Wernicke, " Die apatische Symptomen Complex," 1874. 

3 Kiissmaul, " Disturbances of Speech," Ziemssen's " Cycle," vol. xiv. 



202 DISEASES OF THE BRAIN. 

ollection in the mind of an individual suffering from word-blindness, 
he is, of course, totally unable to read. For the same reason also 
writing becomes an impossibility. It sometimes happens that though 
the memory of the appearance of printed or written words is lost, the 
memory of the form of the various letters may remain. In this case 
the patient can read aloud and can copy, but, of course, does not un- 
derstand what he has read or written. It is similar to a person who, 
without understanding Latin, can read aloud Latin words and per- 
haps pronounce them faultlessly, and yet not comprehend the meaning 
of a single word he has read. 

Agraphia is the loss of the faculty of writing, and may be either 
sensory or motor. Sensory agraphia accompanies word-blindness, for 
it is manifestly impossible to write a word if the memory of the shape 
of the letters is lost. 

Motor agraphia is the loss of the memory of how to make the 
muscular movements necessary in guiding the pen or pencil in the 
formation of letters. Motor agraphia usually occurs simultaneously 
with motor aphasia. 

Paraphasia is the loss of the power of speaking coherently. 
There is little or no difficulty in pronouncing words, but the words 
uttered fail to express their author's meaning, and usually have no sig- 
nificance at all. Thus one patient referred to his boots as his " top- 
sails," while another, in trying to tell the time, called half -past twelve 
" half-past candle-stick." 

Amnesia is the inability to voluntarily recall memory-pictures and 
may involve any of the special senses. A person affected with this 
form of aphasia finds it impossible to recollect the names of people, or 
of objects which should be familiar to him. The memory-picture is 
not destroyed, as it is in word-deafness or in word-blindness, for the 
forgotten word is immediately recognized as soon as it is heard or 
seen, but in most instances it is immediately forgotten again and can 
not be recalled by any voluntary effort of the will. Thus a person 
affected with amnesic aphasia is shown a knife and the question is put 
to him " What is it ? " Immediately he shows by intelligent signs 
that he knows what the object is used for. He will go through the 
motions of opening and shutting the knife, or as if he was cutting a 
piece of stick, and you can frequently see from the expression of the 
countenance that he is making every effort to think of the proper 
name. You ask him: "Is it a watch?" "No." "Is it a bat?" 
"No." "Is it a knife?" "Yes, yes, a knife, a knife— that is it." 
In a moment you hold up the knife again and ask him to name it, 
only to find that he has again forgotten it. 

Apraxia, though not a form of aphasia, frequently occurs with it ; 
particularly with word-blindness and word-deafness. Apraxia is the 
term used to designate the inability of an individual to comprehend 



APHASIA. 203 

the uses or imports of objects. This condition was first described by 
Ktissmaul 1 and more recently by Starr, 2 who reports nine cases of 
apraxia occurring with word-blindness, in all of which autopsies were 
obtained. To detect apraxia it is simply necessary to show to the 
person to be tested several objects with which all people are more or 
less familiar, and see if he recognizes them and uses them for the pur- 
poses for which they were intended. If he fails to do this, then 
apraxia is present. Apraxia is not necessarily confined to psychical 
blindness. There may be apraxia of hearing, of smell, of taste, and of 
the tactile sense. 

Pathology.— The lesions producing the different forms of apha- 
sia are invariably situated in the left hemisphere of the brain in 
right-handed persons, and in the opposite hemisphere in left-handed 
persons. 

The lesion resulting in motor aphasia is situated in the posterior 
part of the inferior frontal convolution, or Broca's convolution as it 
is sometimes called, and perhaps in the contiguous region of the an- 
terior central convolution where the centres for the lips and tongue 
have been located. Lesions in the motor conducting paths below 
this Tegion of the cortex also produce motor aphasia, and, as Gow- 
ers 3 points out, if the lesion is immediately below the cortex, the 
aphasia becomes permanent, since a lesion in this position would 
involve the commissural fibres, as well as the fibres of the direct 
speech tract, and thus there would be no pathway for the outward 
transmission of motor speech impulses. But if the lesion affects the 
speech tract lower down, as, for instance, in the internal capsule, 
then the aphasia will be transient, because the motor impulses can 
pass from the centre on the left side to the corresponding centre in 
the righ.t hemisphere, thence through the right internal capsule to the 
lips and tongue. 

Word- deafness is due, as was first pointed out by Wernicke, to a 
lesion, involving the posterior two-thirds of the first temporal convolu- 
tion. It is probable that a lesion of the posterior part of the second 
temporal convolution will also result in word-deafness. 

Word blindness is produced by a lesion involving the angular 
gyrus and the supra-marginal convolution. 

The situation of the lesion resulting in motor agraphia has not 
been definitely determined, but recent investigations lead to the 
belief that it is to be found in the motor centres for the fingers in the 
posterior central convolution. 

The accompanying diagram (Fig. 16), modified from Naunyn, 
illustrates the position of the lesions in the forms of aphasia just de- 
scribed. 

* Ktissmaul, op. eit. 2 Starr, Med. Rec, October 27, 1888. 

3 Gowers, " Diseases of the Nervous System," 1888. 



204 



DISEASES OF THE BRAIN. 



In paraphasia we are again indebted to the careful researches of 
Wernicke for the first absolute knowledge of the situation of the 
lesion resulting in this form of aphasia. Wernicke's cases led him to 
believe that paraphasia was due to a lesion of the association tracts 
between the word-speaking centre in the posterior part of the inferior 
frontal convolution and the word-hearing centre in the temporal con- 
volutions. Recent post-mortem investigations confirm this view. 



Fig. 16. 




The lesion is usually found to involve the island of Reil and the parts 
directly under it. The island of Reil lies directly over the association 
tract passing between the word-speaking and the word-hearing centres. 
Although the lesion is usually situated in the position just mentioned, 
a lesion which involved this association tract in any part of its course 
would be attended by the same result. 

In simple amnesia the situation of the lesion is not definitely 
known. Starr 1 advances the theory that "auditory amnesia is caused 
by a lesion in the association tracts leading to the temporal convolu- 
tions, in distinction from word-deafness due to a lesion in those convo- 
lutions." This theory is plausible, but is unsubstantiated, as its 
author admits, by postmortem evidence. It would certainly seem 
probable, when the appearance of an object fails to arouse the recol- 
lection of its name, and that feeling it, tasting it, or smelling it, if 
these are possible, enables the individual to recall the name desired, 
that the lesion must be in the association tracts and not in the cortical 
centre. But when it becomes impossible for an individual to spon- 
taneously think of a word, of the name of an object, or of the name of 

1 Starr, op. cit. 



APHASIA. 205 

a person, in which case neither the special senses nor the association 
tracts are necessarily used at all, then Starr's theory becomes unten- 
able. The lesion in such a case probably lies in the same situation 
as the lesion for word-deafness — that is, in the posterior part of the 
first and second temporal convolutions, but, unlike the lesion producing 
word-deafness, it does not destroy the memory-picture, but simply 
inhibits its regeneration. The lesion producing apraxia with word- 
blindness is situated in the temporo-occipital region. Apraxia is not 
confined to psychical blindness. There may be apraxia of any of the 
senses, but as yet there is no post-mortem evidence to prove the 
location of any of these forms of apraxia except apraxia with word- 
blindness. 

The following cases illustrate the different forms of aphasia. 

Case I. 3Iotor Aphasia. — W. W., aged forty-one, entered the 
New York State Hospital for Diseases of the Nervous System, August 
22, 1870, hemiplegic on the right side, and affected with ataxic aphasia. 
In the month of March, 1868, as ascertained by Dr. Cross, the resi- 
dent physician of the hospital, he was seized with a dull pain in the 
right knee, accompanied with numbness, formication, and pricking 
sensations, limited to the right foot, while general numbness of the 
whole side soon supervened. These, with loss of power, gradually 
extended and increased till at the end of two weeks the patient was 
entirely hemiplegic. There was at no time any loss of consciousness 
nor any mental aberration. On the 11th of May following, the 
patient suddenly lost the power of speech, but his mind remained per- 
fectly clear, and, though he could not utter a word, he understood 
well everything that was said to him. He remained nearly com- 
pletely aphasic for four months, being only able during that time to 
utter a few sounds, which could not be interpreted into intelligible 
words. 

About September, 1868, he began to enunciate a few words, at first 
very slowly and indistinctly, and gradually acquired more facility. 
When I presented him before the class at the Bellevue Hospital 
Medical College, in November, 1870, although he could talk, his 
power of co-ordination was very imperfect, and many words were 
articulated with great difficulty. This trouble was chiefly manifest- 
ed in regard to labials and Unguals, such words as " truly rural," 
" Peter Piper," " baker," and others of the kind, causing him to make 
repeated efforts before he could even imperfectly pronounce them. 
There was no paralysis of the tongue, no deviation when it was pro- 
truded, and but very slight if any paresis of the orbicularis oris or 
other facial muscles. The arm and leg on the right side were pro- 
foundly paralyzed. 

In this case there was no loss of the memory for words, and 
no difficulty in writing. It was, so far as the aphasia was con- 



206 DISEASES OF THE BRAIN. 

cerned, entirely motor in character, and accompanied by right hemi- 
plegia. 

My opinion is that there had been a lesion involving the motor 
division of the internal capsule and that the recovery from the aphasia 
was due to the fact that the lesion was too low down to affect the 
commissural fibres passing through the corpus callosum, and that the 
speech impulses were eventually transmitted through this channel in 
the manner previously mentioned. 

Case II. Amnesia and Partial Motor Aphasia. — A. E., formerly 
a bookseller, consulted me in the autumn of 1869 for what was con- 
sidered by his friends to be, and what probably was, softening of the 
brain. Before any symptom of disease appeared he had been noted 
for his remarkable memory, but was now exceedingly forgetful, 
especially as regarded words. Thus he had forgotten his first name, 
and could not tell me the names of his children. His conversation 
was marked with great hesitancy, from his not remembering the 
words he wished to use, and there was, besides, marked difficulty 
of articulation, and some words he could not pronounce at all. There 
was right hemiplegia, which bad gradually been getting worse, and 
which, when I saw him, was extensive enough to interfere materially 
with the movements of his arm and leg. The left side was not affected, 
and the tongue and face were apparently not paralyzed. He was sub- 
sequently lost at sea in the City of Boston. 

This case, therefore, exhibited both the amnesic and motor forms 
of aphasia, and was accompanied by right hemiplegia. I regard the 
condition as being due to thrombosis, probably of the left middle cere- 
bral artery. 

Case III. Word-deafness with Auditory Amnesia, Word-blind- 
ness, and Apraxia. — C. D., aged forty-six, consulted me in October, 
18S6, for epilepsy. He was a Frenchman, but had been in America 
many years and spoke English fluently. He had had epileptic attacks 
for two years, at first infrequently, but lately as often as five or six 
times a day. Under treatment the attacks diminished to about one a 
month. On Christmas Day, 1888, he had a sudden attack of hemipa- 
resis on the right side of the body, which was, however, unattended 
by loss of consciousness. Examination showed that he was word-deaf, 
but only for English icords. Any remark addressed to him in French 
was readily comprehended and replied to in French, but he was totally 
unable to understand anything said to him in English. There was 
also amnesia for English words. When asked in French to tell the 
English names of different objects which were shown to him, he could 
not do so, although he promptly named them in French. He was also 
word-blind, but only for English icords. French books he could read 
and discuss intelligently, but English books he could not read at all. 
There was no apraxia present at this time. 



APHASIA. 207 

I saw him again on May 5, 1889. The right arm was completely- 
paralyzed, the right leg partially so. Word-deafness was complete 
for both English and French words. He could talk fairly well in the 
French language, but was totally unable to understand a single word 
that was said to him. Word-blindness was now present for both Eng- 
lish and French words. He was therefore unable to read in either 
language. Apraxia was also observed. He did not know what a 
match was used. for. At his meals it was noticed that he did not 
know what his fork was for, although he could have used it perfectly 
well, as his left arm was not paralyzed in the slightest degree. Many 
other objects, the uses of which he had formerly understood, were 
now shown to be utterly unknown to him. 

I saw him for the last time on July 3d. There was no change in 
his condition except that the right leg had become completely para- 
lyzed. He died the following month, but no post-mortem examination 
could be obtained. 

Case IV. Motor Aphasia, Paraphasia, and Word-blindness. — 
H. I., a merchant, consulted me in August, 1869, for hemiplegia, with 
inability to speak. While sitting at his desk, six weeks previously, he 
suddenly became vertiginous, and lost consciousness for a few moments. 
On recovering his senses, he discovered that he was paralyzed on the 
right side, and that he could not speak a word. He was exceedingly 
anxious to make known some wish, and one of his clerks brought him 
paper and a pencil, but he could not write a letter. An alphabet was 
then written, but he was unable to select the letters to form the words 
he wanted to use. 

A physician was sent for, and Mr. I. was bled to the extent of six- 
teen ounces, without any favorable result. He remained hemiplegic 
and completely aphasic for about two weeks. He then began to walk, 
and acquired the ability to say "what," " certainly," and " saw my leg 
off," which he contracted into " sawmelegoff," accentuating strongly 
the ultimate syllable. These words he used without apparent intelli- 
gence, though he clearly understood all that was said to him, and 
laughed at any joke as heartily as ever. His condition was about the 
same when I saw him. 

He could protrude his tongue and move it actively in all directions, 
but could not articulate any words but those mentioned. Thus, when 
I asked him to say " table," he said " Certainly " ; and when I said 
" Well, say it, then," he exclaimed, " Sawmelegoff ! " At the same 
time, to show that he understood what I said, he went across the room 
and put his hand on a table, uttering, at the same time, his full stock 
of words, " what," " certainly," " sawmelegoff." 

I then asked him if he could write ; he replied, " Certainly." I 
placed paper before him, and gave him a pen with ink, but he was 
unable to write his name as I requested, although he could use his 



208 DISEASES OF THE BRAIN. 

fingers for other things tolerably well. I asked him to draw a series 
of parallel lines, and he did so without difficulty. On my insisting 
that he should now make an effort to write his name, he made the 
attempt with the result shown in the accompanying woodcut (Fig. 
17). I told him that was not his name, at which he gesticulated 

Fig. 17. 

violently, exclaimed " Sawmelegoff ! " and gave me one of his vis- 
iting-cards. This gentleman continued under my care for some time, 
but with no perceptible change. He had had two attacks of acute 
articular rheumatism, and had, when I saw him, both aortic and 
mitral insufficiency. My diagnosis was embolism of the left middle 
cerebral artery. 

Case V. Paraphasia. — Captain C, an officer of the mercantile 
marine, was attacked in September, 1874, with sudden loss of the 
power of speech, attended with confusion of ideas, and vertigo. He 
soon recovered, but had several subsequent seizures, characterized by 
vertigo, impairment of language, and slight delirium. I first saw him 
on the 31st of October, and on the 28th of November he went with me 
to the University of New York, where he was one of the subjects of 
my clinical lecture on aphasia, delivered to the medical class. At this 
time, and for several weeks previously, he had constantly used words 
which were without relation to the things he wished to name. Thus, 
if he wanted his boots, he would ask for his top-sails, or would be apt 
to employ some other word designating part of a ship. In his con- 
versations with me he continually exhibited this peculiarity. There 
was no want of memory for any other parts of speech than substan- 
tives. For instance, I held up a penknife before him ; he at once 
said it was to cut with, but when I pressed him to name it, he called 
it a " boat." A thermometer was an " anchor," and a watch was a 
" capstan." When I asked him to say "National Intelligencer" he said 
"National intelligence-office," and, no matter how often I repeated 
the words, he always said " National intelligence-office." The reason 
for this was very obvious : he had frequently had occasion to say 
"intelligence-office," but had probably never before in his life been 
asked to say "National Intelligencer" After a time he succeeded in 
acquiring the power to utter the final " e ?*," but then he placed it in 
the wrong position, and said " National intelligence-officer." Syllable 
by syllable, he could speak these words correctly, but they were at 
once forgotten. 

Case YI. Paraphasia and Agraphia. — Mrs. L., forty-three years 



APHASIA. 209 

of age, consulted me in December, 1888. About a month previous 
to my seeing her she had awakened at her usual time in the morn- 
ing and found that her right arm and leg were very much weak- 
ened. At that time the peculiarity of her speech was observed and 
had continued ever since. She was able to pronounce many words 
perfectly, while other words were frequently mispronounced. Thus, 
" pouring " was "pawling," a "battery" was a "battlewag," aud 
"vaseline" was "very green." There was also a tendency to sub- 
stitute a word or words in a sentence in place of the proper words, 
so as to make the sentence incoherent. Thus she said that "she 
had just been to peppermint," meaning, however, that she had just 
been to church. "Half-past twelve" she called " half -past candle- 
stick." She was also unable to write a single word. With a pen or 
a pencil she could draw fairly well, and could copy letters with con- 
siderable accuracy. 

Case VII. Motor Aphasia and Word-blindness. — G. E., a noted 
physician of this city, was suddenly stricken with apoplexy. On re- 
gaining his consciousness it was observed that, although he compre- 
hended everything that was said to him, he could not speak a single 
word spontaneously, neither could he repeat words when asked to 
do so. Thinking that he might be able to express his thoughts by 
means of letters formed into words, an alphabet was brought to 
him, but he could not arrange the letters so as to form words. He 
had lost the visual memory of the letters. When words were formed 
from the letters and shown to him, he failed to comprehend them. 
He had therefore lost the visual memory for words also. This con- 
stitutes a perfect example of word-blindness accompanied by motor 
aphasia. 

Case VIII. Amnesia and Agraphia. — During the winter of 
1868-'69 a man came to my clinic, at the Bellevue Hospital Medical 
College, who was aphasic, and from whose friends, his own gest- 
ures, and the few words he could speak, I obtained the following 
history : Some months previously he had been working in a stone- 
quarry, and was struck by some piece of machinery on the left side of 
the head, at about the junction of the frontal with the temporal bone. 
For a short time he was unconscious, recovering, however, without 
paralysis, but with loss of the memory of words. When he came 
under my observation he was very intelligent, comprehended every 
word said to him, and made repeated and persistent efforts to talk, but 
he could not utter a word spontaneously beyond " yes " and " no," 
which he always used correctly. Thus, when I asked him where he 
was born, he became much excited, gesticulated violently, and appar- 
ently made every effort to tell me. The perspiration stood out in 
large drops on his forehead, but no sound came from his lips. Then 
the following conversation took place: "Were. you born in Prus- 
15 



210 DISEASES OF THE BRAIN. 

sia?" "No." "In Bavaria?" "No." "In Austria?" "No." 
"In Switzerland?" "Yes, yes, yes — Switzerland, Switzerland," at 
the same time laughing, and moving his hands actively in all direc- 
tions. He could pronounce words well, but could not write. 

I took occasion to speak at length on the subject of aphasia, and 
gave it as my opinion that there had been a fracture of the internal 
table of the skull, and that a fragment of bone was pressing on the 
posterior and lateral part of the anterior lobe. Prof. Sayre was pres- 
ent, and I advised him to trephine the patient, with the view of elevat- 
ing any depressed piece of bone, and restoring the normal function of 
that part of the brain. The operation was performed a few days 
afterward, the patient being placed under the influence of ether. The 
internal table was found to be fractured, and a splinter was pressing 
on the anterior central convolution. It was removed, and, as soon as 
the patient emerged from the anaesthetic condition, he spoke perfectly 
well. 

Case IX. Motor Aphasia and Agraphia, folloieed by Parapha- 
sia. — J. H., a captain of a coasting- vessel, consulted me in November, 
1864, for difficulty of speech with which he had been affected for sev- 
eral months. Upon inquiry, I. ascertained that one morning early he 
had been called from his bed upon some duty connected with his ves- 
sel ; that he had risen rather hastily and gone on deck ; that while 
giving an order he suddenly became very dizzy, and fell, unconscious. 
He soon regained his senses, but found that he was paralyzed on the 
right side, and had lost the ability to speak. It was subsequently 
ascertained that he had also lost the ability to write. He could under- 
stand all that was said to him and could read. His agraphia and 
aphasia were therefore both motor. He soon afterward reached port, 
and remained at home for three months, during which period the 
paralysis disappeared almost entirely, and he reacquired the ability to 
speak and to write. 

He then went to sea again as a passenger to Cuba, and while in 
Havana had another attack similar to the first, but without paralysis of 
motion, though there was loss of sensibility on the right side. The 
memory for words was entirely destroyed, though he could pronounce 
distinctly any word he was told to say, if he did not allow too long a 
period to elapse between the direction and the response. About four 
months after his last seizure he consulted me. 

At this time he could say a few words, and he employed them to 
express all his ideas, assisting himself with very energetic gestures, 
which, however, were rarely expressive of his thoughts. The words 
he thus constantly used were " sifi," which signified both " yes " and 
"no," and "time of day," which he employed when he had any other 
answer than a simple affirmative or negative to give. Besides these 
expressions, he had an oath, " Hell to pay ! " which, he ejaculated 



APHASIA. 211 

whenever he did not succeed in making himself understood, and some- 
times without any such exciting cause. These were the only expres- 
sions he could originate, but he could pronounce distinctly any word 
he was told to say, and even as many as three short successive words. 
When told to write, he took the pen, and, on my telling him to give 
me his name and address, wrote " Time of day," and then, seeing that 
that was not the correct answer, immediately followed it with " Hell 
to pay ! " On my remarking to him that he had given me wrong 
information, he immediately wrote " sifi." Any word, however, which 
I told him to write, he did without any difficulty, and thus I obtained 
several long sentences from him. 

From his brother, who came with him, I obtained the facts in his 
history I have mentioned. Examining his heart, I found that he had 
a strong systolic murmur, and was told by his brother that he had had, 
fifteen years ago, a first attack of acute articular rheumatism, which 
had been followed by several other attacks. 

Many other cases of aphasia have come under my observation, but 
it is scarcely necessary to mention them in detail, as they present no 
features differing in any material point from those cited. 

It will be observed, however, that simple uncomplicated cases of 
any one form of aphasia are uncommon. Motor aphasia occurs more 
frequently than any other form, and is more liable to occur independ- 
ently of any other variety of aphasia. The reason for this is obvious. 
Motor aphasia frequently accompanies ordinary hemiplegic attacks 
resulting from a cerebral hemorrhage, involving the anterior two- 
thirds of the internal capsule. In such a case only the motor tract is 
injured, and, of course, only motor aphasia is produced. This aphasia 
is usually transient, which is in direct contrast to motor aphasia of 
cortical or immediately subcortical origin. On the other hand, word- 
deafness, word-blindness, and amnesia are more frequently caused by 
embolism or thrombosis of an artery which results in the softening of 
quite an extensive area of the cortex. It is for this reason that word- 
blindness and word-deafness are so frequently associated. 

As to the causes, the prognosis, diagnosis, morbid anatomy, and 
pathology, they have been sufficiently considered in the remarks made, 
and the treatment is of course that of the pathological condition to 
which it is due, whether this be cerebral haemorrhage, embolism, throm- 
bosis, softening, hysteria, wounds, the bites of poisonous serpents, syph- 
ilis, or other cause. One point,* however, should be mentioned in this 
connection, and that is that constant efforts should be made to develop 
the uninjured speech-centre, and to exercise the vocal organs by con- 
stant attempts to speak. The application of the galvanic or faradaic 
currents to the tongue and other muscles concerned in articulation is 
a measure of usefulness. 



212 DISEASES OF THE BRAIN. 

r 
CHAPTER VIII. 

ACUTE CEREBRAL MENINGITIS. 

By acute cerebral meningitis is understood inflammation of two 
membranes of the brain — the pia mater and arachnoid. Some writers 
have made the attempt to discriminate between inflammation of the 
arachnoid and inflammation of the pia mater, but there are no diagnostic 
marks by which such a distinction can be made, and we find from post- 
mortem examination that neither membrane can be inflamed without the 
other participating in the morbid process. Inflammation of the dura 
mater is never included under the term meningitis. 

The ancients made no distinction between the several inflammatory 
affections of the intra-cranial organs, but comprehended them all in one 
disease, which they called frenzy — (pprjv, the brain. Morgagni, however, 
showed that the membranes of the brain were the parts generally 
involved, and gave a very accurate account of the phenomena of an 
attack of acute meningitis. Since then, Rostan, Lallemand, Andral, 
Bouillaud, and others, have added to our knowledge. 

Symptoms. — The symptoms of acute cerebral meningitis may be 
divided into three groups, arranged in chronological order: the stage of 
invasion, the stage of excitation, and the stage of collapse. 

1. The Stage oe Invasion. — The most prominent initiatory symp- 
tom is headache, which may be diffused or confined to a limited part of 
the head. When this latter is the case, the frontal region is more gen- 
erally its seat; next in order of frequency is the occipital, and next the 
temporal. At the same time the face is flushed, the eyes are red and 
suffused, and there is a decided elevation in the temperature of the head, 
which is not only felt by the patient, but may be perceived by the hand 
of the physician. Vomiting is generally present. 

As might be expected, these symptoms are accompanied by fever. 
This, however, rarely runs high, so far as the force or the frequency of 
the pulse is concerned, or as regards the heat of the skin. It is mainly 
characterized by restlessness and insomnia. Occasionally there is a 
tendency to somnolence. 

This stage may last a few days or only a few hours, or may be so 
slight as not to attract attention. In general features it resembles 
the prodromatic stage of cerebral congestion. 

2. The Stage of Excitement. — A chill ushers in this stage, 
and an increase in the intensity of several of the symptoms of 
the first stage and the development of others soon take place. 
Thus the fever becomes higher, the skin hotter, and the tempera- 
ture of the body is elevated several degrees — the thermometer rising 



ACUTE CEREBRAL MENINGITIS. 213 

as high as 105°, 106°, and sometimes to 107°. The pulse is fre- 
quent — rising to 120, or even 160 — quick and hard, and the face be- 
comes redder than in the first stage. The pain in the head augments 
in violence, and is increased by pressure on the scalp, or even the 
slightest movement. 

The eyes are bright, the pupils contracted and painfully sensitive to 
light. The hearing becomes morbidly acute, loud noises cause great 
agony, and even slight sounds are unbearable. The general sensibility 
of the body is increased, and hence the patient is rendered uncomfort- 
able by the contact of the bedclothes with the skin. Delirium is gen- 
erally present from the first, and is often of furious character. Hallu- 
cinations of sight and hearing are almost constant, and the irrationality 
of the ideas is marked by the incoherence of the speech. The patient 
when awake is continually talking, gesticulates violently, and weepa 
and laughs alternately over imaginary evils. It is sometimes necessary 
to use restraint to prevent him injuring himself or others, and the 
attendants should always be prepared for any emergency of the kind. 
As the disease advances, the delirium becomes more subdued, and the 
patient may exhibit some evidences of sanity. 

Even when there is no delirium, as occasionally happens, the influ- 
ence of the morbid action over the mind is shown in the irritability of 
the patient, and the change which he undergoes in character and dis- 
position. 

Convulsions rarely occur in adults, but motility generally is never- 
theless disordered. The limbs are in almost continual action, as are 
likewise the jaw and the eyelids. Twitchings of the facial and other 
muscles, such as those of the forearm, are usually well marked, and 
occasionally there are irregular movements of the eyeballs. Convul- 
sions, when they occur, may be either clonic, or tonic, or both. Thus 
there may be a gradually-increasing rigidity of some muscles, followed 
by relaxation and disordered movements. Sometimes there is opis- 
thotonos as well marked as in some cases of tetanus. Hemiplegia or 
paraplegia may occur, but are infrequent complications. I have seen 
two cases in which one lateral half of the body was paralyzed during 
the whole course of the disease. 

Contractions of the limbs sometimes take place, and may be con- 
fined to one side or to a single limb. In this case the forearm is usu- 
ally strongly flexed on the arm. 

The muscles of organic life participate, and the bowels are obsti- 
nately constipated. There may be difficulty of swallowing, from spasm 
of the pharynx, and irregularity of breathing, from implication of the 
respiratory muscles. 

The most characteristic symptom of this stage is, however, the 
obstinate and violent cephalalgia, of which mention has already been 
made, and yet there are cases in which it is entirely absent from first 



214 DISEASES OF THE BRAIN. 

to last. Several such instances have been under ray own charge, and 
post-mortem examination has verified the existence of the evidences 
of meningitis. This stage lasts from a few days to two weeks. 

3. The Stage of Collapse. — The beginning of this stage is marked 
by the occurrence of somnolence, which often shows a tendency to pass 
into coma, and by a subsidence of the delirium and muscular agitation. 
There are times, however, during which the stupor remits in profundity, 
and the patient appears to be somewhat conscious of his condition, but 
these periods only occur in the first part of the third stage. Ere long 
the coma becomes constant. 

Paralysis then supervenes, and is first manifested in the ocular or 
facial muscles. Thus from paralysis of one of the muscles of the eye- 
ball strabismus ensues, or the upper eyelid may drop from paralysis of 
the levator palpebrae superioris. The pupils dilate and become insensi- 
ble to light, and the mouth is drawn to one side from implication of the 
muscles of the face. Before long the contractions of the limbs relax, 
and paralysis takes place. The sphincters of the bladder and rectum 
also lose their power, and the urine and fasces escape involuntarily. 
The pulse becomes slow and irregular, but the temperature, as Jaccoud 
has shown, and as I have lately verified in several instances, does not 
fall. Some authors regard this reduction in the frequency of the pulse 
while the heat of the body remains high, as pathognomonic. The in- 
sensibility becomes more and more profound, and the patient dies in a 
state of coma, sometimes from asphyxia produced by paralysis of the 
respiratory muscles, but generally from the gradual engorgement of the 
lungs, and with a bodily temperature as high as at any other period of 
the disease. 

Such is the ordinary course of an attack of simple acute cerebral 
meningitis occurring in a young and healthy person. Though it is cer- 
tainly true, as post-mortem examinations have shown, that the mor- 
bid process may be general or limited to the convex or basilar surface 
of the brain, or to the ventricular lining, yet during life the distinction 
cannot be made, mainly for reasons which will be given under the h ead 
of pathology. But there are modifications often met with which require 
consideration. Of these, epidemic cerebro-spinaf meningitis, though 
scarcely to be considered a disease of the nervous system, and tubercu- 
lar meningitis, will be discussed under other heads, but the differences 
due to acute rheumatism and old age may very properly be noticed in 
the present connection. 

RHEUMATIC MENINGITIS. 

Under the name of cerebral rheumatism, several very different affec- 
tions of the brain supervening during the course of acute articular 
rheumatism have been embraced. The relation of rheumatism to such 
secondary diseases has long been recognized, but very great confusion 



ACUTE CEREBRAL MENINGITIS. 215 

has existed in regard to the exact nature of the morbid processes set 
up in the brain and its membranes. That meningitis may, however, be 
one of these conditions, appears to be quite certain. Gintrac 1 has col- 
lected twenty-one cases of cerebral meningitis the result of rheumatism, 
or at least occurring in conjunction with that disease, the existence of 
which was established by post-mortem examination. Oulie 3 con- 
tributes four others, and many more are to be found in medical treatises 
and periodicals. 

Although I have witnessed a number of cases of what in former 
editions of this work was designated cerebral rheumatism, I have only 
had one case in which the existence of meningitis as a consequence of 
rheumatism was demonstrated by post-mortem examination. 

The membranes of the brain are most liable to be affected during 
the latter stage of an attack of acute rheumatism, but there seems to be 
no doubt that the cerebral disease in question may supervene at any 
time during the course of the primary disease, and that it sometimes 
has all the appearance of being a true metastasis. The symptoms which 
indicate the supervention of cerebral meningitis are delirium, convul- 
sions, or more frequently choreiform movements in the limbs, tremor, 
especially about the lips and muscles of the face, paralysis in various 
parts of the body, and stupor. Pain and vomiting, which are such con- 
stant features of ordinary meningitis, are rarely present in the rheu- 
matic form of the affection. The bodily temperature is not elevated 
more than three or four degrees above the normal standard. Toward 
the last, coma, if already present, becomes more profound, or if not, 
makes its appearance, and death ordinarily ensues. Occasionally, how- 
ever, recovery takes place. 3 

SENILE MENINGITIS. 

In old persons, the symptoms of acute meniDgitis are rarely so 
pronounced as in individuals of middle age. The affection comes on 
more gradually, and may have made considerable progress before its 
existence is suspected. There is little or no pain, no fever, and no 
gastric or intestinal derangement. The mental symptoms are very 
similar to those due to softening. The patient has imperfect articu- 
lation, his memory is impaired, and he does things which show that he 
is not in his right mind. The delirium is of the low muttering kind, 

1 Op. tit., tome iii., p. 11. 

2 "Du rheumatisme cerebrale." These de Paris, 1868. 

3 In a very valuable memoir on " Cerebral Rheumatism," just published, Prof. Da 
Costa 1 has given the details of twelve cases in which cerebral symptoms supervened dur- 
ing the course of articular rheumatism. Dr. Da Costa expresses the opinion that all cases 
of what is called cerebral rheumatism are not characterized by the presence of meningitis, 
and the results of the post-mortem examinations which he obtained from his cases, cer- 

1 American Journal of the Medical Sciences, January, 1875, p. 17. 



216 DISEASES OF THE BRAIN. 

and there is a tendency to coma even in the first stage. There is a 
more or less general paresis in all the limbs, and subsultus is com- 
monly present. Death is usually due to pulmonary engorgement. 

Causes. — Among the predisposing causes of acute cerebral menin- 
gitis, age is first to be considered. Guersant ' asserts that the period of 
life between sixteen and forty-five is that during which acute menin- 
gitis is most liable to occur, not including children, who are far more 
prone to the disease than adults. Rilliet and Barthez 2 have, however, 
shown that very young infants are not so subject to simple acute menin- 
gitis as children of from five to eleven years of age. The very oppo- 
site opinion is expressed by Drs. Meigs and Pepper. 3 

Thirteen cases of acute simple meningitis have come under my ob* 
servation. Of these, all were between the ages of thirty and forty. 

Men are more subject to it than women. Of my cases, ten were 
males and three females. Parent-Duchatelet and Martinet, 4 however, 
think women are more predisposed to the affection than men. 

Temperature, either very high or very low, predisposes to acute 
meningitis. Eight of the cases under my care occurred in summer and 
five in winter. 

Certain professions and habitudes appear to favor the occurrence 
of the disease. Among the former are all those which require the head 
to be exposed to strong and direct heat ; among the latter are exces- 
sive intellectual exertion, and abuse of alcoholic liquors. Tertiary 
syphilis, gout, and rheumatism are likewise predisponents. 

Larrey 5 states that in the retreat of the French army from Russia, 
the soldiers, who had endured the most terrible sufferings from hunger 
and cold, were attacked, on their arrival in Konigsberg, where they had 
ample food and warm quarters, with cerebral meningitis, which in gen- 
eral proved fatal. This result was probably due to the operation of 

tainly support this view. But in Case I. — a very characteristic instance — the brain was 
not examined ; Case Y. recovered ; in Case VI. the brain was not examined ; in Case 
VIII., also a marked case, in which there were flushing of the face, occasional spasmodic 
contractions of the facial muscles, contracted pupils, undulatory motions of the body, and 
tossing of the arms, an examination was refused ; in Case IX., iri which there were mental 
symptoms, facial paralysis, ptosis, and hemiplegia, the patient recovered ; in Case XI. re- 
covery took place, as it did also in Case XII., so that in only six were there post-mortem 
examinations of the encephalon. 

Dr. Da Costa does not doubt the existence of rheumatic meningitis, but he contends, 
and I think successfully, that all cases of cerebral disorder, originating during the course 
of articular rheumatism, are not cases of meningitis, and that in some cases there are 
actually no abnormal post-mortem appearances. 

1 Art. " Meningite," in " Dictionnaire de Medecine," Paris, 1839. 

2 "Traite des maladies des enfants," Paris, 1853. 

3 "A Practical Treatise on the Diseases of Children," Philadelphia, 1870, p. 464. 

4 " Recherches sur l'inflammation de l'arachnoide," Paris, 1821. 

5 "Memoires de chirurgie militaire et campagnes," Paris, 1817, tome iv., p. 139. 



ACUTE CEREBRAL MENINGITIS. 217 

many causes besides prolonged exposure to a low temperature, among 
which the sudden removal of the mental tension maintained by the 
exigencies of the situation in which the army was placed, was not the 
least. 

Of exciting causes, injuries of the head from falls or blows of differ- 
ent kinds stand first. Next is exposure to the direct rays of the sun, 
or other source of great heat, and then recession of an exanthematous 
affection, such as scarlatina, measles, or erysipelas, and the irritation of 
dentition, or intestinal worms. 

Acute cerebral meningitis sometimes prevails epidemically. Such 
was the case with the series of instances which came under Larrey's 
observation, and others have been noted. 

Diagnosis. — Acute meningitis may be confounded with partial or 
circumscribed encephalitis, but the distinction is made by considering 
that in the latter the headache is less severe, the delirium less marked, 
and the convulsions and contractions weaker. Moreover, the febrile 
excitement is much greater in acute meningitis than in partial enceph- 
alitis, and the whole disease more pronounced. 

The meningitis of the aged bears a considerable degree of resem- 
blance to cerebral softening; but the fact that the first-named affection 
is more rapid in its progress, and is not preceded by symptoms due to 
other morbid conditions, will generally enable the practitioner to make 
a correct diagnosis. 

From delirium tremens it may be distinguished by the history of 
the case, by the greater tendency to insomnia exhibited in alcoholism, 
and by the general character of the delirium. The febrile excitement 
of acute meningitis, the pain in the head, the heat of the skin, the ab- 
sence of clammy perspiration, and the increased temperature, as shown 
by the thermometer, are conclusive diagnostic marks. 

From typhoid fever meningitis is diagnosticated by the existence 
in the former of meteorism, abdominal tenderness, and petechias, by 
the facts that the headache and febrile excitement are less, and that 
diarrhoea is present and vomiting is not. 

Prognosis. — This is always grave. Occasionally death takes place 
in a very few hours, and generally before the tenth day. When the 
disease is prolonged beyond this latter period, the prognosis becomes 
more favorable. The occurrence of strabismus or other paralytic 
affection lessens the hope of a favorable termination. Prof. Flint, 
however, has cited two cases occurring in the hospital practice of 
himself and Dr. Thomas, in which there were strabismus, hemiplegia, 
and coma, both of which recovered. He also cites another case in 
which there was strabismus, and in which recovery took place. Hic- 
cough is an unfavorable event. 

Of the thirteen cases observed by myself, eleven died. In all of these 
fatal cases there was strabismus. In the two cases which recovered 



218 DISEASES OF THE BRAIN". 

there was no squinting. The deaths in the fatal cases all occurred be- 
fore the tenth day, and two took place before the end of the third day. 

Morbid Anatomy. — If death occurs during the second stage of the 
disease, the most marked appearance found in the membranes is red- 
ness from increased hyperemia. If, however, it is delayed till the third 
stage, thickening and opacity of the membranes and adhesions to each 
other, and of the pia mater to the brain, and effusion of serum, are the 
prominent features. In a case in which I made a post-mortem exami- 
nation in. the summer of 1870, and which was caused by the great heat 
of the season, there was an extensive collection of bloody serum in the 
cavity of the arachnoid, and the pia mater was so adherent as to bring 
with it a layer of the gray matter of the brain as it was stripped off. 

The fluid may consist solely of pus, or this may be mingled with 
serum in all proportions. The pus, with the fibrine of the exuded serum, 
often forms thin plates of membraniform texture, which are scattered 
over the surface of the inflamed region or may entirely cover it, and 
which are of the nature of false membranes. 

If death has taken place late in' the course of the disease, evidences 
of the implication of the cerebral substance will generally be discerned. 
.These consist in the gray matter becoming of a pinkish color, and the 
white, when cut, showing numerous puncta vasculosa. The ventricles 
rarely contain any considerable amount of fluid, and are often entirely 
empty. The latter was the case in the instance above mentioned. 

Pathology. — The symptoms of the first and second stages are due 
to congestion; those of the third mainly to effusion and consequent 
pressure. 

An important question connected with the pathology relates to the 
determination, from the symptoms, what part of the brain is the seat 
of the lesion. The convex surface of the hemispheres is intimately 
related to the purely intellectual functions of the brain and to the fac- 
ulties of motion and sensibility, while the under surface, or base, is 
connected more with the special senses and is closely in apposition with 
the various cranial nerves. Thus, if the inflammation be strictly lim- 
ited to the upper surface of the brain, the predominant symptoms are 
those involving intellectuality, and consequently there is delirium 
marked by incoherence of ideas and irrationality of language. There 
are muscular contractions, spasms, convulsions, and paresis or paraly- 
sis of various groups of muscles in proportion to the extent of the in- 
flammation over the motor areas. Disturbances of sensibility, such as 
headache, tactile and thermic anaesthesia, hyperesthesia, analgesia, and 
paresthesia, are frequently observed. If, on the contrary, the base of 
the brain alone is affected, the resulting symptoms are principally due 
to the implication of the cranial nerves. Thus optic neuritis is a symp- 
tom frequently observed, and can usually be detected in a few days 
after the onset of the meningitis by a careful ophthalraological exami- 



ACUTE CEREBRAL MENINGITIS. 219 

nation. The third nerve is frequently affected, producing strabismus 
and ptosis. The facial nerves are occasionally implicated in one or 
more of their branches, and the auditory nerve, which accompanies the 
facial in a part of its course, is likewise prone to suffer. When these 
two nerves are affected, facial paralysis and deafness result. If the 
hypoglossal nerve on one side only is inflamed, the tongue will be para- 
lyzed on one side, and will deviate toward the side of the lesion. If 
both nerves are affected, the tongue can only be protruded with great 
difficulty, or else not at all. When the morbid action extends to both 
the convexity and the base, there is a combination of these phenomena. 

Treatment. — To afford any chance of a favorable result, the treat- 
ment should be energetic from the first. 

General bloodletting may be practised with advantage in subjects of 
good constitution and of the middle period of life. As many as twelve 
or sixteen ounces may be taken from the arm if the pulse is hard, the 
cephalalgia intense, or the delirium furious. Leeches applied behind 
the ears or to the inside of the nostrils are more generally of advantage. 
The same may be said of cups to the nucha. 

The hair should be cut off short, and ice kept constantly applied to 
the scalp during the first and second stages. It is better than the cold 
douche, for the reason that it is almost impossible to continue the latter 
without intermissions, during which the head again becomes hot. Com- 
presses wrung out of cold water will not answer; they soon get heated, 
and act as poultices. Irrigation, by a small stream of ice -water falling 
from a vessel placed above the head of the patient, is a useful means of 
applying cold, but is often inconvenient. 

The experiments of Dr. Benham 1 appear to show that cold applied 
to the head has no material effect in reducing the intra-cranial tempera- 
ture, or in lessening the amount of blood flowing to the brain. But it 
must be borne in mind that, though cold applied to the scalp may not 
reduce the normal intra-cranial temperature, it may exercise a very 
different influence over temperature which is abnormally high, and that 
his experiments with Ludwig's Strohm-uhr were but three in number, 
that the cold was only applied for thirty minutes, and that it is quite 
doubtful if the Strohm-uhr affords the best means, under the circum- 
stances, for determining the quantity of blood flowing to the brain. 
In actual experience, we find that the sedative influence of cold to the 
head is as well-established a fact as any other in therapeutics, and, 
though it may fail, as every other remedy does some time or other, to 
produce its expected effect, that fact should be no reason against our 
employment of it in cases in which it appears to be indicated. In acute 
cerebral meningitis, I have repeatedly seen the violence of the symp- 
toms mitigated by the agent in question, but, in order to obtain this 

1 "On the Therapeutic Value of Cold to the Head," "West Riding Lunatic Asylum 
Medical Reports," vol. iv., 1874, p. 152. 



220 DISEASES OF THE BRAIN. 

result, it should be kept persistently applied in the forms above men- 
tioned. 

Purgatives are generally advantageous and should be effective. 
Nothing is better than croton-oil, although calomel and podophyllin, 
grs. x with grs. ij, make a good combination for the purpose. 

My experience has satisfied me of the good effects of mercurializa- 
tion. I have administered calomel in doses of a grain every two hours 
until the breath became fetid, and I am sure the effect has been bene- 
ficial. 

The iodide of potassium is well spoken of by Dr. Flint, 1 who says he 
has witnessed the good effects of the drug in several cases. Dr. F. R. 
Lyman 2 has reported two cases in which it formed a prominent feature 
of the treatment, and in which recovery took place. 

Within late years in the few cases of acute cerebral meningitis that 
have been under my charge, I have found the greatest benefit from the 
bromide of potassium, and the three cases that recovered were instances 
in which it was administered in large doses. The theory upon which its 
employment is based has alieady been fully considered in the chapter on 
cerebral congestion. It should be administered in doses of at least thirty 
grains three or four times a day, from the very beginning of the affec- 
tion to the end of the second stage or the appearance of coma, should 
this symptom supervene. 

The head should be kept well elevated, the chamber cool, and well 
ventilated, the light in a great measure excluded, and the utmost quiet 
enjoined. 

The food, without being stimulating, should be nutritious. Nothing 
is superior to strong beef -tea, made either from fresh beef or from some 
one of the extracts in the market. 

In the third stage the treatment should be almost the reverse of that 
indicated as proper for the first and second stages. The mercury, iodide 
of potassium, bromide of potassium, ice to the head, and purgatives 
should be omitted, and attention should be given to the maintenance 
of the strength. To this end brandy, whiskey, or other alcoholic 
liquor, should be administered in such quantities- as the occasion seems 
to require. It often happens in this stage that the delirium and exces- 
sive motility return. It must be remembered that this is not from any 
renewal of morbid processes within the cranium, but is entirely due to 
debility. At the moment of writing this, a young lady of this city is 
under my charge for acute cerebral meningitis, whom I did not see till 
the third stage was well advanced, and who for several days previously 
had exhibited a return of the delirium, for which depletive measures 
and hydrate of chloral had been employed. The free administration of 
brandy, champagne, and beef -tea, soon dissipated the symptoms of re« 
lapse, and she bids fair to recover. 

1 Op. cil, p. 601. 2 American Medical Times, 1862, p. 334. 



CHRONIC CEREBRAL MENINGITIS. 221 

Blisters may be used in this stage with advantage. They are 
best applied between the shoulders, and should be six or eight inches 
square. 

In the rheumatic form of the disease little special treatment is neces- 
sary. It is, perhaps, advisable to endeavor, by means of blisters or 
other revulsives, to bring back the disease to the joints. 

In the acute meningitis of the aged, active depletive treatment is not 
so generally admissible, and if apparently indicated should be carried 
out cautiously. It may even be proper to treat some cases with stimu- 
lants from the very first. 



CHAPTER IX. 

CHROmC CEREBRAL MENINGITIS. 

Although it is scarcely possible, for reasons given in the preceding 
chapter, to determine from the symptoms the exact seat of the morbid 
process in an attack of acute cerebral meningitis, we are often able, in 
the chronic form of the disease, to make the differential diagnosis with 
sufficient accuracy. I shall therefore consider the affection according to 
its location under the heads of Chronic Verticalar Meningitis, and 
Chronic Basilar Meningitis, the terms being applied respectively to 
chronic inflammation of the membranes of the superior surface or vertex 
of the brain, and chronic inflammation of the membranes of the inferior 
surface or base of the brain. 

I. CHRONIC VERTICALAR MENINGITIS. 

This disease may be the consequence of an attack of acute cerebral 
meningitis, or may originate without being thus preceded. The latter 
is the usual mode of development. 

Symptoms. — The symptoms of chronic verticalar meningitis are in 
some respects similar to those of general paralysis, an affection which 
will be fully described as one of the forms of insanity; and they also 
resemble those evolved during the course of softening, limited to the 
convex portion of the brain. 

Among the physical symptoms headache occupies a prominent posi- 
tion and is usually the first evidence of cerebral disease which attracts 
the attention of the patient. The pain is generally felt in the fore- 
head, in one or both eyes, or at the vertex, and is aggravated by men- 
tal exertion, by the mere act of reading or fixing the attention, by mus- 
cular effort, or by a dependent position of the head. It is not usually 
very intense, but is characterized by persistency. There are frequent 
attacks of vertigo. Somnolency is generally present, and there are 



222 DISEASES OF THE BRAIN. 

trembling, defective articulation, weakness of the limbs, spasms of par- 
ticular muscles or groups of muscles, paralysis of the bladder or of the 
sphincters of the bladder and rectum, producing involuntary discharges 
of urine and fasces, weakness of the memory, especially as regards 
words, and a general enfeeblement of the mental faculties. Occa- 
sionally there are epileptic convulsions. 

Paralysis of the whole of one side of the body may ensue, or the 
loss of power may be confined to a single limb, or to a group of mus- 
cles. Anaesthesia may be present, either general or local, or there may 
be neuralgic pains in various parts of the body, sometimes of a very 
persistent character. The ocular muscles are not often implicated, 
either by spasm or paralysis; and the special senses, except that of gen- 
eral sensibility, are not usually impaired. Convulsions of an epilepti- 
form character are not uncommon. 

Unless the cortical substance of the brain participates in the morbid 
action there is not ordinarily marked mental aberration, although there 
is a general failure of mental power. Under the name of " general 
paralysis," : and subsequently of " chronic, diffused periencephalitis, 2 " 
Calmeil described a disease which is now well known, and in which the 
cortical portion of the upper part of the cerebrum is in a condition of 
chronic inflammation, the membranes of the region being also involved. 
But the peculiarities of general paralysis are so well marked as to ne- 
cessitate separate description. 

The ophthalmoscope does not, in this affection, generally reveal any 
very notable changes in the fundus of the eyes. Occasionally, where 
there is reason to suspect its existence, there is ischasmia papillae, and 
still more rarely neuro-retinitis. As Dr. Allbutt 3 has remarked, the 
optic nerves in drunkards affected with meningitis of the convex surface 
of the brain " are often degenerated, and the vessels injected, but these 
effects do not seem to be due to any meningitic process." When, 
however, the meningitis is complicated with inflammation of the cortical 
substance of the brain, neuro-retinitis is a frequent accompaniment. 

The general health participates more or less in the disturbance. 
The stomach is irritable, and vomiting is frequent, the bowels are 
usually obstinately constipated, and the urine is scanty and high- 
colored, often containing oxalate of lime and an excessive amount of 
uric acid. 

As the disease advances, the mental and physical symptoms become 
more and more pronounced. The mind is weaker, delirium is not in- 
frequent, convulsions occur oftener, and the paralysis extends and be- 
comes more profound. Blindness from pressure upon the optic nerves 

1 "De la paralysee considered chez les alienes," Paris, 1826. 

2 "Traite des maladies inflammatoires du cerveau," Paris, 1859- 

8 " On the Use of the Ophthalmoscope in Diseases of the Nervous System," etc., Lon- 
don and New York, 1871, p. 108. 



CHRONIC CEREBRAL MENINGITIS. 223 

may result. A state of continued coma now supervenes, during which 
the patient expires, or death takes place in convulsions. 

The duration of the disease varies from two or three months to one 
or more years. 

An interesting case of meningitis affecting the membranes at the 
convexity of the brain, is that of the eminent Swiss savant De Saussure, 
related by Dr. Odier. 1 T . 

For many years M. de Saussure had been accustomed to great bodily 
fatigue, and to various degrees of atmospheric pressure, encountered 
in the many ascents of mountains he had made. He had been subject 
to an aggravated form of dyspepsia, and to repeated large losses of 
blood from haemorrhoids. 

At the end of the year 1793, after having lost his fortune, and ex- 
perienced a good deal of mental disturbance from the unsettled condi- 
tion of the national affairs, he was suddenly seized with vertigo, which 
was followed by distinct sense of numbness in the left arm and cheek. 
The vertigo did not last Ions: but nothing could relieve the feeling of 
numbness or torpor. Blisters, purgatives, tonics, and anti-spasmodics, 
were employed in vain. The affection of the arm seemed to be seated en- 
tirely in the sentient nerves, for the patient retained his strength, could 
perform all kinds of movements, but could not distinguish easily what 
he was touching. It seemed to him as if sand were interposed between 
his ringers and the bodies with which he brought them in contact. 
The sensation experienced was rather painful than otherwise, so that 
he was indisposed to use his hands unless they were protected with 
gloves. A similar feeling existed in the cheek and mouth on the same 
side, which, on passing his hand over his face, formed, in the most un- 
pleasant manner, a well-marked line of demarkation between the right 
and left side. In other respects he was well; his general health was 
not impaired, and he retained for a long time his presence of mind and 
the fullness of his intellectual powers. Many months were passed in 
this state, during which a great variety of remedies were tried, such as 
cold and warm bathing, electricity, arnica, valerian, blisters, embroca- 
tions, artificial and natural thermal waters, change of regimen, travel- 
ing, etc., but all in vain. The disease became worse and worse; always, 
however, by starts, the attacks being more or less violent and complete. 
One of the most violent was occasioned suddenly at Bourbon, by a 
shower-bath employed too warm. The attack produced by it was so 
complete that the whole of the left side, from the leg to the tongue, was 
affected. His articulation became by degrees indistinct and unintelli- 
gible. His legs, especially the left, became weaker, and his gait was 
staggering, and he found it almost impossible to maintain his equilib- 
rium and to direct his steps as he wanted. He experienced peculiar 

1 " An Account of the Illness and Death of H. B. de Saussure, late Professor of Phi' 
losophy at Genova," Edinburyh Medical and Surgical Journal, vol. ii., 1806, p. 393. 



224 DISEASES OF THE BRAIN. 

difficulty in passing through doors, even when they were wide open, 
and no descent or ascent to make. As he approached a door he bal- 
anced himself, and quickened his motion as if he had to make a dan- 
gerous leap or a bad step to get over; when it was done he recovered 
his equilibrium, crossed the room, but had the same trouble in order 
to get to another apartment. Day by day the disease advanced; the 
intellectual faculties became perceptibly weaker; incontinence of urine 
supervened. The evening before his death he seemed to enjoy his sup- 
per, but was restless during the night; toward morning his head leaned 
to one side, he breathed with more difficulty than usual, and expired 
without agony. 

On opening the body thirty-two hours after death, the dura mater 
was found adherent to the cranium, particularly along the longitudinal 
sinus, but that deviation from the natural condition was not considered 
of importance, it being often met with unassociated with intra-cranial 
disease. Between the pia mater and the arachnoid there was found 
a considerable effusion of a bluish gelatinous substance. In various 
places there were circular spots of a gray yellowish color about two or 
three lines in diameter. These seemed as though they penetrated into 
the membranes, though susceptible of being detached from them like 
small separate spheres surrounded by a little circular margin of a dark- 
red color. At first sight these spots were taken for hydatids, but closer 
examination showed that the red margin was a blood-vessel connected 
with other vessels, and convoluted in the form of circles. There were 
no separate pouches or solutions of continuity in the membranes, only 
they were more transparent in those places than in others. The seros- 
ity underneath communicated freely with that which was diffused over 
all the surface of the brain, both having the same color and qualities. 
On opening the membranes the serous effusion ran off like water. The 
effusion existed not only over the surface of the cerebrum, but also 
over that of the cerebellum. The ventricles also were distended with a 
similar fluid. The examination of the brain presented nothing more of 
importance except that it was flattened on the surface and deeply 
furrowed by arteries. The total duration of the disease was five years, 
although the beginning may have been anterior to the apparent time 
of origination, as it was stated that Prof, de Saussure, long before his 
death, had often mistaken one word for another in conversation, and 
was so unconscious of his error as to get angry when not understood. 

Dr. Odier attributed the death of the patient to the effusion of a 
large quantity of serum into the ventricles and between the membranes 
of the brain. That this effusion resulted from chronic meningitis is 
scarcely a matter of doubt. 

Gintrac 1 cites the following case: " A young man sixteen years old, 

1 Op. cit, tome ii., p. 626. Quoted from Bruce, " Medico-Chirurgical Transactions," 
London, 1818, vol. ix., p. 280. 



CHRONIC CEREBRAL MENINGITIS. 225 

very tall, was attacked in December with feebleness of sight, strabismus, 
dilatation of the pupils, diplopia, and headache ; pulse natural, consti- 
pation, epistaxis; convulsions, with foaming at the mouth; coma and 
stertor, which were relieved by bleeding from the temporal artery, but 
which returned twenty-four hours later. Delirium supervened, charac- 
terized by violent language, and attempts to strike and bite those 
around him ; pulse frequent. The wound in the artery being reopened, 
repeated losses of blood occurred, and the convulsions returned. Sight 
weakened, ideas confused, appetite voracious, general debility, but 
power of walking, of comprehension, and of speech, remained. Then 
somnolency, attended with spasmodic movements of the muscles, es- 
pecially of those of the face, appeared. The face was red and swollen, 
especially on the left side. Death occurred in violent convulsions two 
months after the beginning of the disease. 

" The cerebral blood-vessels were found to be very much injected. 
On the left anterior lobe there was a slight effusion of blood; a little 
serum in the ventricles; substance of the brain firm; numerous puru- 
lent spots along the line of superior longitudinal sinus." 

M. Casimir Broussais 1 submitted to the Academie de M6decine a 
pathological specimen with the history, of which I give the main 
points : 

Lozeray, a sapeur pompier, twenty-two years old, entered the hos- 
pital Val-de-Grace August 1, 1840. Six days previously he had been 
attacked with headache and slight fever. The evening of his entrance 
he was bled. He improved, the pain disappeared, and his appetite re- 
turned. On the 7th of August he had a relapse; hardly answered the 
questions addressed to him; remained motionless in bed; was entirely 
paralyzed in the right arm and leg; was again bled. The next day, 
being comatose, venesection was again practised, and twenty leeches 
were applied to the temples. On the 9th the paralysis had disappeared, 
but, as he was still comatose, another venesection was performed, and 
fifteen leeches w^ere applied to the neck over the jugular vein.- On the 
10th was bled again; still comatose, and the right arm contracted. On 
the 12th had epileptic paroxysms, during which it was remarked that 
one side was more convulsed than the other; coma profound; eighteen 
leeches to the jugulars; 14th, 15th, and 16th, same symptoms; an 
enormous bed-sore on the sacrum. On the 18th coma less complete; 
epileptic convulsions, especially in the night. From this time he con- 
tinued to improve till the 28th, when coma again supervened, and on 
the 29th he died. 

On post-mortem examination the dura mater was found healthy. 
On being incised, a quantity of sero-purulent fluid escaped. The mem- 
brane was adherent to the brain, principally on the convex surface, 
and especially on the right side, so that it was impossible to detach it 

1 "Bulletin de Pacademie royale de medecine," tome v., 1840, p. 564. 
16 



226 DISEASES OF THE BRAIN. 

entirely without rupture. On the right side it formed a sac extending 
over about three-fourths of the convex surface, containing from two 
hundred to two hundred and fifty grammes of a greenish-white sero- 
purulent fluid. Another sac, containing from fifty to sixty grammes of 
this fluid, existed on the left side. 

The dura mater was removed, and it was ascertained that this fluid 
came from the cavity of the arachnoid and from the meshes of the pia 
mater. 

In the case of a gentleman under my charge there was intense head- 
ache as the first prominent symptom, followed by epileptiform convul- 
sions, and varying degrees of paralysis, both of motion and of sensa- 
tion on one side of the body and again on the other. When I first 
saw him the optic nerves had been so injured by the pressure from 
effused fluid as to cause complete blindness. Light could not be dis- 
tinguished from darkness. The ophthalmoscope showed extreme atro- 
phy of both nerves, probably either the result of pressure or the conse- 
quence of neuritis from extension of the cerebral disease. The accumu- 
lation of fluid was so great as to force open the bi-parietal, the fronto- 
parietal, and the occipito-parietal sutures. Under treatment the excess 
of fluid disappeared, the pain ceased, and he acquired the power of 
vision to such an extent as to enable him to tell light from darkness, 
and even to make out the figures on a bright carpet. He died, how- 
ever, about six months after leaving New York, of cancer of the stom- 
ach. There was no post-mortem examination of the brain, or none that 
was reported to me, but I am strongly of the opinion that the disease 
was chronic meningitis of the convexity of the brain, resulting in a large 
effusion of serum. 

Causes. — The etiology of chronic cerebral verticalar meningitis is 
often difficult to make out. Sometimes, however, the affection is the 
result of an acute attack. At times it clearly originates from blows or 
falls upon the head, and again it is caused by exposure to the heat of 
the sun or to artificial heat. There is certainly a form of chronic in- 
flammation of the membranes of the convex surface of the brain, which 
is due to the extreme heat of the sun, not necessarily to the action of 
the direct rays, and which is characterized by the symptoms I have speci- 
fied. I see some cases of this every year in New York, and have wit- 
nessed several similar instances in cooks and others whose occupations 
necessitated the exposure of the vertex to intense or long-continued 
heat. 

The affection in question may also be induced by mental influence, 
especially anxiety and other forms of emotional disturbance ; and this 
category of causes is probably the most influential of all others, with 
the single exception of excessive alcoholic potations. So far as our 
knowledge extends, this last is the most common factor in the causation 
of chronic verticalar meningitis. 



CHRONIC CEREBRAL MENINGITIS. 227 

Syphilis is another influential cause, though generally, as we shall 
see hereafter, it acts preferably upon the basilar portion of the mem- 
branes. 

It is probably sometimes induced by rheumatism and gout, and cer- 
tainly occasionally by tubercular deposit, but when arising from this 
last-named cause it is not to be confounded with tubercular cerebral 
meningitis, the seat of which is in the membranes at the base of the 
brain, and which is otherwise differently characterized. 

Diagnosis. — This is often impossible to be made out, with even a 
moderate degree of exactness, and is always more or less difficult. The 
affection may be confounded with inflammation and softening of the 
cortical substance of the cerebrum, and the most careful study will in 
many cases fail in discriminating between them. The difficulty is fre- 
quently heightened by the fact that the two diseases coexist. But we 
are much assisted by a thorough investigation, not only of the symp- 
toms, but of the causes. For instance, a category of phenomena such 
as has been given, resulting from exposure to intense heat, is generally 
due to chronic inflammation of the membranes of the superior surface 
of the brain, and the same may be said of syphilis. When, however, 
the symptoms follow undue mental exertion or emotional excitement, 
the distinction is more difficult, and indeed in such cases the substance 
of the cortex is usually also involved. 

In general, the pain which is so prominent a feature in inflammation 
of the membranes, is not so marked an accompaniment of softening, 
while in the latter the mental disturbance is greater than when the 
morbid process is confined to the meninges. From inflammation of the 
membranes at the base of the brain, the affection under consideration 
is distinguished by the almost constant absence of ocular paralysis, 
and by the fact that the seat of the pain is different, and that the mind 
is more decidedly involved. 

The ophthalmoscopic appearances will suffice for the diagnosis from 
anaemia or hyperemia of the brain, or from megrim or neuralgia, even 
if the other points in the clinical history are not sufficient. 

Prognosis. — The prognosis in cases of chronic inflammation of the 
meninges of the convex surface of the brain is decidedly unfavorable, 
unless a syphilitic origin can be made out, in which event the prospect 
of recovery is good. But even in such a case the disease must be early 
subjected to proper treatment, for the disposition to extend to the sub- 
stance of the brain which the affection so often manifests, and the fact 
that new formations are liable to be produced and to exert an abnormal 
influence upon the nerve-tissue, very greatly increase the probability of 
an unfavorable result. 

Nevertheless, I am satisfied that even where there is no suspicion of 
syphilis, chronic verticalar meningitis is sometimes successfully com- 
bated. This point will be further considered under the head of treat- 



228 DISEASES OF THE BRAIN. 

ment. In the mean time I quote the following case from Dr. E. L. 
Fox, 1 of Bristol, England, in which a post-mortem examination gave 
evidence of the previous existence of the disease in question. It is 
possible there was a syphilitic taint in this case, though nothing is said 
on the subject: 

" The patient, a young man, had died of an attack of hasmorrhage, 
from rupture of the right middle meningeal artery, but the dura mater, 
all over the convex surface of the hemispheres, was somewhat adherent 
to the subjacent arachnoid, while the arachnoid was thickened and yel- 
low all over. This patient had been under Mr. Parker's care a year be- 
fore, with great pain all over the upper part of the head, without any 
delirium, and had been treated, with entire success, with iodide of po- 
tassium. In this case, therefore, arachnitis had existed without any 
lesion of the cerebral matter itself, and without delirium." 

Morbid Anatomy and Pathology. — The essential features in the mor- 
bid anatomy of chronic cerebral verticalar meningitis are hyperaemia 
of the vessels and a new formation of connective tissue by which the 
membranes adhere to each other and to the brain, and by which they 
are rendered opaque, and thicker than normal. 

In addition, there may be deposits of exudation on the convexity 
of the brain which, though intimately connected with the alterations of 
the membranes, are yet distinct from them. These, as characterized 
by Gintrac, 2 may consist of serum effused under the arachnoid, of a 
thick, gelatiniform, discolored fluid in the same situation, of pus con- 
tained either in the cavity of the arachnoid or infiltrated into the 
meshes of the pia mater, of false membranes formed in the cavity of 
the arachnoid, non-adherent, adherent to one or other layer of this 
membrane, or double, composed of an external layer of the arachnoid, 
and an internal, adherent to the visceral lamina, thus constituting cysts, 
which may contain blood-serum or other matter. 

Of one hundred and sixty-seven cases of meningitis of the convexity 
of the brain collected by Gintrac — in which, however, the distinction 
between the acute and chronic forms of the disease is not drawn — the 
relative proportion of morbid conditions was as follows: 

Injection, opacity, or thickening of the membranes 9 

Serous exudation 33 

Gelatiniform exudation 14 

Pus 30 

False membranes 81 

Total 167 

Fox 3 has very clearly shown that tubercle may be associated with 

1 " Clinical Observations on Acute Tubercle," " St. George's Hospital Reports," Lon- 
iou, 1869, vol. iv., p. 61. 

2 Op. tit, tome ii., p. 604. * Op. et loc. cit. 



CHRONIC CEREBRAL MENINGITIS. 229 

chronic meningitis of the convexity of the brain. The following case, 
which I cite from him, is so interesting in several respects, that I quote 
it in full, so far as the description relates to the brain: 

" Case XXII. — Henry B., aged twenty-four, tailor; ill one month 
with pain in the forehead; no cough. When first examined in recum- 
bent position, a sharp, blowing, systolic murmur was heard at the base 
of the heart, traveling up toward the left shoulder; a little later he had 
sickness, then intense pain, chiefly at back of head. Head jerks back- 
ward at every beat of the heart; much cerebral throbbing. Temporary 
relief from blisters, cold to the head, and purgatives; but eventually 
more sickness, diplopia, which, however, was intermittent, and in- 
creased headache. Then almost total freedom from pain, and all mor- 
bid symptoms, and he was able to be out; but he died suddenly in a 
fit, three months from the commencement of his illness. No bronzing 
of skin. 

"Post-mortem Examination. — Dura mater externally seemed healthy; 
internally it was firmly adherent to the subjacent tissues at the spots 
below mentioned; veins of convex surface of hemispheres tinged with 
blood. On left hemisphere, about middle of brain, was a spot of tuber- 
culous matter the size of a filbert, which seemed to be immediately con- 
nected with the vessels of the pia mater, to have become adherent on 
the one side to the dura mater, and on the other to have extended 
through the gray matter for a few lines into the white. The two lat- 
eral and third ventricles much distended with clear fluid, containing a 
few small, white flakes. Foramen of Monro enlarged sufficiently to 
contain a small nut. Walls of ventricles very soft; optic thalami 
tolerably firm. Corpora striata excessively pulpy; pons and medulla 
oblongata everywhere rather soft. On anterior lobe of right hemi- 
sphere, just on the lateral surface, was another tuberculous spot the size 
of a nut. On the external surface of the cerebellum, close to the floc- 
culus on left side, though not involving it, was a large mass of tubercule, 
dipping into the structure of the cerebellum, and uniting this organ to 
the posterior lobe of the left cerebral hemisphere. More than three- 
quarters of the left half of the cerebellum were occupied by large ves- 
sels of the same growth, which apparently had grown separately, and 
by gradual increase of size had at length become one mass. The dura 
mater was adherent over a great part of this side of the cerebellum, 
and the cerebellar structure that remained was almost diffluent. The 
other side of the cerebellum was also much softened." 

This case is remarkable, not only for the intermittence in the symp- 
toms, to which Dr. Fox calls attention, but also for the lightness of the 
phenomena when compared with the severity and extent of the lesions. 
Such remissions in the manifestations of cerebral disease as were ex- 
hibited in this case, though not unusual, are, in the present state of our 
knowledge, not easy of explanation. For it is very evident that there 



230 DISEASES OF THE BKAIN. 

was a steady advance of the morbid processes up to the very instant 
of death, and yet the patient died suddenly, having up to that time 
passed through a period of almost entire freedom from pain and all 
morbid symptoms. 

I am tempted also to cite the next case from Dr. Fox's memoir, on 
account of a like slightness of symptoms existing in connection with 
extensive cerebral lesions. 

Case XXIII. — Catharine S., aged thirty-one, servant; single; pale, 
lean woman; has had vertigo and pain in back of the head for five weeks; 
no sickness, no rigors, pulse now very feeble and hurried. Tongue 
coated; skin hot; no sickness until eight days after admission, and she 
coughed first on the ninth day. Became delirious, but was always capable 
of answering questions reasonably, and the chief symptom was a gradu- 
ally increasing weakness of pulse. Sank quietly out of life, without 
coma, on the twenty-second day after admission, having had no convul- 
sions throughout, and no cerebral respiration until the last day of life. 

" Post-mortem Mcamination. — Cranium : Arachnoid, and subjacent 
tissues on convex surface of the hemispheres, contained much clear 
fluid, but were otherwise natural. Between the cerebral hemispheres 
and the longitudinal fissure were a number of small, miliary tubercles, 
and at the lower part of this fissure the opposed hemispheres were ad- 
herent to each other by means of a mass of tuberculous matter the size 
of a nut. A small portion of similar matter was found at the upper 
part of the cerebellum, connected with the arachnoid. The venous 
tissue around these tuberculous masses was very much softened and 
ecchymosed. Two similar masses were also found in inner wall of pos- 
terior horn of each lateral ventricle. Ventricles full of turbid fluid, and 
their walls softened." 

It sometimes happens that chronic inflammation of the membranes 
of the vertex of the brain exists without the occurrence of notable 
symptoms. Several such cases have come under my own observation in 
which, after death, the membranes were found thickened, opaque, and 
adherent, and in which, during life, no complaint of cerebral disturb- 
ance had been made. It is probable, however, that symptoms of such 
disturbance have existed, but have not been mentioned by the patient. 

Treatment. — The treatment depends to some extent upon the cause, 
although the general management of the disease is not subject to any 
very essential variation, however it may originate. Thus the iodide of 
potassium is in all cases the agent most to be relied upon. When the 
affection is due to syphilis, or has followed syphilitic infection, the iodide 
must be administered with much more persistency and in larger doses 
than when not so associated. In all cases, however, it must be given in 
what may be called large doses, and must be continued for several 
months. In uncomplicated cases the quantity administered may be at 
first ten grains three times a day, gradually increased to thirty grains 



CHRONIC CEREBRAL MENINGITIS. 231 

for each dose; but in syphilitic cases the doses will often have to be 
carried to eighty or even a hundred grains thrice daily. The iodide of 
potassium should, in my opinion, always be given in gradually- increas- 
ing doses. This is best effected by using a saturated solution of the 
medicine in water, each minim of which contains about a grain of the 
salt. For the first day ten minims may be given three times, for the 
second day eleven, and so on till the maximum dose, which it may be 
deemed proper to administer, is reached. I have several times had 
cases under my charge in which no sign of amelioration occurred till 
doses of from eighty to one hundred grains thrice daily were used. 

Some one of the bromides may be very advantageously given in 
addition to the iodide of potassium. The bromide of calcium is to be 
preferred in almost all cases. It acts more rapidly than the others, and, 
notwithstanding the recent opinion of a German physician, more effect- 
ually. The doses should be about fifteen grains daily, and each dose 
may be given with that of the iodide of potassium. It must not be 
forgotten that these medicines must, when taken, be administered 
in a large quantity of water (half a tumbler, for instance). They act 
better, and are less liable to irritate the stomach, when they are well 
diluted. 

Under the combined action of the bromide and iodide, the relief 
from all symptoms of intra-cranial disease is often very striking. This 
is especially apt to be the case when syphilis is at the bottom of the 
morbid process. 

Relative to the propriety of administering mercury in chronic cere- 
bral verticalar meningitis, much depends upon the nature and duration 
of the disease. In non-syphilitic cases it is not indicated, nor in those 
instances in which the syphilitic infection is remote, but, where the pri- 
mary disease is recent, mercury is of service as an addition to the other 
measures. It may be given in the form of the biniodide, or the bi- 
chloride, in doses of the sixteenth of a grain two or three times a day. 

For the relief of the pain, which is sometimes very severe, a pill con- 
taining half a grain of codeia may be prescribed with advantage, as 
often as required. 

In regard to local medication, I am inclined, from more recent ex- 
periences, to believe that blisters applied to the nape of the neck are 
occasionally beneficial. As a rule, however, I do not employ them, or 
any other revulsive or counter-irritant means. 

The patient should be instructed not to over-exert the mind, to avoid 
all causes of excitement, mental or physical, and live in strict accord- 
ance with hygienic principles. 

CHROMIC BASILAR MENINGITIS. 

Chronic basilar meningitis is very seldom the consequence of an 
acute attack, probably mainly for the reason that acute inflammation 



232 DISEASES OF THE BRAIN. 

of the membranes at the base of the brain is almost invariably a fatal 
affection. 

Symptoms. — Although there is generally pain from the very incep- 
tion of chronic basilar meningitis, the first very decided symptom is 
sometimes an epileptiform paroxysm. Or there may be convulsive 
movements of a limb, a group of muscles, or a single muscle, unat- 
tended with loss of consciousness. 

Again, there may be tonic spasms of the muscles of one or more of 
the extremities, especially of the arms; or the muscles of the neck may 
be similarly affected, causing the head to be fixed in an abnormal posi- 
tion. The individual muscles of the face are not usually involved. 

But ordinarily the primary serious indication of intra-cranial dis- 
ease is paralysis. This may appear in the head, arm, the hand, or a 
single finger; or one side of the tongue may be affected, giving rise to 
defective articulation, and to a deviation toward the paralyzed side 
when the tongue is protruded, or the muscles supplied by the seventh 
nerve may be affected and facial paralysis be produced. In the great ma- 
jority of cases, however, some one of the motor nerves of the eyeball is 
first involved in the morbid process, and this is generally the third nerve 
of one side, resulting in ptosis, external strabismus, and diplopia, dila- 
tation of the pupil, and defective power of accommodation. 

Sometimes the implication of the third nerve is not complete. Thus, 
there may be paralysis of the levator palpebrae superioris muscle, pro- 
ducing ptosis, or the internal rectus muscle of the eyeball may be par- 
alyzed, causing the globe to be rotated outward by the uncompensated 
action of the external rectus, and as a consequence producing double 
vision; or, what is more rarely the case, the superior or inferior rectus, 
or the inferior oblique, may lose the power to act. In a few cases, the 
only indication of the affection of the third nerve is dilatation of the 
pupil. 

The fourth nerve may be paralyzed, and then the loss of power is 
limited to the superior oblique muscle, and the ability to rotate the eye- 
ball outward and downward is impaired; and again, the lesion is only 
manifested as regards the sixth nerve and the external rectus muscle, 
so that internal strabismus is the result. Occasionally the first sign of 
the disease is aphasia, with or without vertigo, confusion of ideas, or 
loss of consciousness. 

It not infrequently happens that pain of a very severe character is 
for a long time the only symptom which disturbs the patient. It may 
be located in some part of the head, or may be referred by the patient 
to the face, and is often regarded and treated as ordinary neuralgia. 
The chief features of this pain are its intensity and persistency. I have 
known it to last, without interruption, night and day, for over four 
months, driving its subject to the Yerge of insanity, and causing him to 
Dntertain serious thoughts of suicide. 



CHRONIC CEREBRAL MENINGITIS. 233 

In a few of the cases which have come under my observation, the 
principal symptom was anaesthesia of certain portions of the cutaneous 
surface. The skin of the face appears to be particularly liable to this 
phenomenon, although I have seen it extend throughout the whole of 
one side of the body; again, confined to the lower extremities; and at 
other times to the trunk, or upper extremities. In one case this was 
unaccompanied by paralysis of motion anywhere, but in the others the 
muscles, or some of them supplied by the third nerve, were paralyzed. 
In a case reported by Petrequin, 1 and cited by Lagneau, 2 of syphilitic 
necrosis of the frontal bone, and in which there was certainly also 
chronic basilar meningitis, the lower limbs were deprived of sensibility 
for two months. 

Vertigo is almost always a prominent symptom, and may be so intense 
and persistent as to prevent the patient walking without support. At 
times it is impossible for the recumbent position to be abandoned, even 
for an instant, without the supervention of severe dizziness; at others 
it occurs unexpectedly, and may be the cause of the individual falling. 

The eyesight is often impaired from a very early period. This may 
be due to paralysis of the accommodation, resulting from loss of power 
in the iris and ciliary muscle, especially the latter; for, though the iris 
probably has some influence in effecting the adjustment of the lens for 
different distances, it is in the ciliary muscle, as Von Graef e has shown, 
that the function mainly resides. The defect in question is shown by 
the difficulty which the patient experiences in distinguishing near ob- 
jects. There is no trouble in seeing images at a distance, but the effort 
to read, for instance, is unsuccessful — the lines of print appearing 
blurred — and always increases the pain in the head, besides inducing 
temporary pain in the eye. The exact degree of impairment of accom- 
modative power may be ascertained by the use of Snellen's test-type, 
or still better by Galezowski's typographical scales. 3 

Or the asthenopia may be the result of the paralysis of the internal 
rectus muscle. 

Again, the defective vision may be caused by the disturbance in the 
special nervous apparatus of the eye. Examination with the ophthal- 
moscope almost invariably reveals the existence of hypersemia of the 
optic nerve and retina, and not infrequently of optic neuritis, caused 
by extension of the morbid process from the cerebral membranes to the 
optic nerve. Sometimes, as in cases to be cited presently, vision may 
be entirely lost from this cause; but, again, it is indubitable, as Dr. 
Hughlings Jackson has very definitely shown, 4 that a great degree 

1 Gazette Medicate de Paris, 1836, tome iv., p. 643. 

2 "Maladies syphilitiques du systeme nerveux," Paris, 1860, p. 413. 

3 "Echelles typographiques et chromotiques pour Pexamen de I'acuite visuelle," Paris, 
1874. 

4 Among other places, in the West Riding Lunatic Asylum Reports, in a paper enti. 



234 DISEASES OF THE BRAIN. 

of optic neuritis may exist, and yet the patient be capable of minute 
vision. 

The sense of hearing may also become impaired or lost by extension 
of the inflammation so as to involve the auditory nerve. Several 
cases of the kind have come under my observation; and in one, which 
will be more specifically referred to hereafter, the function was very 
suddenly regained under appropriate treatment. 

Although mental exertion of all kinds adds to the severity of the 
symptoms, it is not usually the case that the mind is primarily affected 
to any considerable extent. There may be periods of depression but 
these are generally the result of the physical phenomena — the pain, ver- 
tigo, paralysis, etc., the sensations arising from or the contemplation of 
which are calculated to disturb the mental equanimity. When, how* 
ever, the mind is brought to bear upon any subject, the intellectual pro- 
cesses are as correct as ever, the only difference being that they cannot 
be long continued without the supervention of fatigue and an aggrava- 
tion of the symptoms. 

It quite often happens that the seat of chronic basilar meningitis 
changes, and with the transference there is an alteration in the locality 
of the symptoms. This is especially seen in the matter of paralysis. 
Thus, in the beginning, the third nerve may be paralyzed, and eventu- 
ally the extension of the lesion leads to the implication of the fourth, 
fifth, and sixth. Cases in illustration of this point, which have occurred 
in my own experience, will presently be adduced. In the mean time, the 
following example from Sir Charles Bell 1 will prove of interest. The 
fact that Sir Charles mistook the real nature of the disease will not de- 
tract from its importance. It is reported as a " Case of Disease of the 
Nerves within the Orbit. 

" Martha Symmonds, aged forty-one, Northumberland Ward. This 
woman was admitted into the hospital for a disease apparently seated in 
the left orbit. Nine months ago she had a paralytic stroke, attended 
with the loss of power in her left arm, neck, and face, on the same side. 
She lost also her power of speech, excepting only to * babble,' as she 
says. She recovered from this attack, and went into service. About 
eight, or ten weeks ago, she was alarmed by a commencing dimness in 
both her eyes, and she was obliged to leave her place on account of this 
dimness of her sight. Both her eyes were equally affected, and there 
was no redness or opacity perceptible in either of them. She placed 
herself under a medical gentleman, because she dreaded a return of the 
palsy. About six weeks ago, the upper eyelid of the left eye fell, and 

tied " A Case of Recovery from Double Optic Neuritis." The case was probably one of 
chronic basilar meningitis, of syphilitic origin. 

1 " The Nervous System of the Human Body. Embracing the Papers delivered to the 
Royal Society on the Subject of the Nerves," London, 1830. Appendix, p. cv. Edition of 
1844, p. 343. 



CHRONIC CEREBRAL MENINGITIS. 235 

she could not raise it. At that time she suffered great pain above the 
left eye, and the pain extended upon the left side of her forehead. She 
at the same time lost the vision of this eye, although she could dis- 
tinguish by it the light of day from darkness. She could direct the 
motions of this eyeball as well as of the other at that time, and the ap- 
pearance of the eye was natural. 

" Five days before she was admitted to the hospital she experienced 
a violent, deep, throbbing pain in her left eye, and from that time the 
eyeball, as she says, became enlarged, until it projected considerably 
beyond the orbit. Two days before her admittance, she was totally 
blind in that eye, and was deprived of sensation on the surface of the 
whole eye, eyelids, the internal corner of the nose, and upon the left 
side of her forehead. 

" At present her left eye is covered with its upper eyelid, and pro- 
jects greatly from its natural situation. The lower eyelid is everted as 
a consequence of the projection of the ball of the eye, and the conjunc- 
tiva is tumid and projecting. She cannot raise the upper eyelid, although 
when it is raised with her finger she can squeeze it down again, and 
winks with a motion which corresponds naturally with that of the other 
eye. It may be a question whether the globe of the eye is enlarged, 
or only protruded. The pupil is unnaturally large, and the iris is 
without motion. She cannot move the eyeball in any direction. The 
whole eye is insensible; she has just had her lower eyelid scarified, and 
she was not sensible of pain. She allows us also to press with our finger 
on the surface of the eye, without complaining of any pain, or winking; 
although, as we said above, she can still wink, and does wink with this 
eyelid when the other eye is threatened. 

" October 6th. — To-day some further examination was made of this 
woman's face and head, in order to ascertain the extent of insensibility. 
It was stated in our last report that she has lost sensation in the sur- 
face of the left eye and eyelids, in the corner of the nose, and upon the 
forehead. In these parts, she says that now the loss of sensation is less 
complete, because when she had her eyelid scarified, the other day, she 
felt pain, which she did not when it was scarified before. The eye also 
seems diminished in size. 

" Besides those parts which we have already described as being af- 
fected, she has, in a partial degree, lost sensibility to touch in that part 
of her cheek which is just under the orbit, and downward upon the side 
of her nose, and upon the left side of her upper lip, and also within the 
cavity of the nose on the left side. However, when the point of the 
pin was brought near to the ear, or upon the skin which is over the 
lower jaw, she then was sensible of pain. A piece of linen was twisted 
so that it might be introduced into the left nostril ; she allowed us to 
push it upward as far as we could, and, during this operation, she only 
remarked that she was sensible of its presence. Turning it about with- 



236 DISEASES OF THE BRAIN. 

in her nostril did not make her sneeze. When we tried the same ex* 
periment on the other nostril, she was unable to bear the tickling pro- 
duced by the loose threads of the cloth, before it was introduced into 
the nostril. Now she informed us that she is in the habit of taking 
snuff; and she is not only insensible to its usually agreeable effects, but 
unconscious of its presence in the left side of the nose. We next made 
her close her right nostril, and inhale strong spirit of ammonia; and 
then repeated the same experiment on the other nostril. There was a 
very obvious difference in the effects produced by the ammonia on the 
two sides of the nose. She told us she could smell the ammonia on 
both sides, but still she could not bear to hold the bottle containing 
the ammonia so long at the right nostril as we observed that she 
could at her left. When the bottle was placed under the right nostril, 
its pungency affected her almost immediately, so much that she could 
not bear it; on the other hand, she allowed it to remain for a consider- 
able time under the left nostril, and even snuffed it up strongly before 
she was inclined to remove it. During these experiments, we observed 
that the right eye became suffused with tears; the left eye, on the con- 
trary, appeared to be dry on its surface. 

" In order to ascertain further to what degree her sense of smelling 
was affected, we tried the effect of some substances which possess odor 
without pungency. On applying oil of anise-seed to her left nostril, 
while the right one was shut, she inhaled it powerfully, but was sen- 
sible of no smell. Then a piece of asafcetida was tried, but still she had 
no kind of sensation, either pleasant or the reverse. She was sensible to 
these odors in her right nostril. 

"The state of her mouth was examined; with the point of a pencil 
we pressed against the upper gums, on the left side of her mouth, and 
the inside of her cheek, where it is reflected off the gums, and she ap- 
peared to have very slight or no sensation at all. She volunteered to 
put a spoonful of mustard between her gums and her cheek, and she 
seemed very little incommoded by such an experiment. The sensibility 
of the other parts of her mouth was natural. 

" The circumstances of this case," continues Sir, Charles, " make it 
difficult to determine exactly where the disease is seated, which thus 
produces the destruction of the optic nerve, the third and fourth nerves, 
the first and second divisions of the fifth nerve, and the sixth nerve. 
Among these nerves we might add the olfactory nerve; but it may be a 
question whether the function of that nerve is directly or indirectly 
affected: the issue of the case will probably determine this matter. 
However, from the condition of the parts without the orbit, we observe 
that the power of closing the eyelid and winking is retained, when the 
power of raising the eyelid is gone, and the sensibility of the eyelids 
and of the eye itself is completely lost. It is the portio dura which is 
distributed to the orbicular muscle of the eyelid, and bestows the power 



CHRONIC CEREBRAL MENINGITIS. 237 

of winking. We see also that she can inhale powerfully, and can per- 
fectly move the muscles belonging to the nostril and upper lip of the 
left side, when at the same time the skin which covers these parts is 
insensible. Still, that power belongs to the portio dura. This nerve, 
passing to the face by a circuitous way, and being, therefore, uninjured 
by pressure within the orbit, permits her to move the left nostril and 
side of her mouth in a natural correspondence with the other side of 
her face, although both the first and second divisions of the fifth nerve 
are included in the disease, and are destroyed along with the first, sec- 
ond, third, fourth, and sixth nerves. 

" May 20, 1829. — Since she left the hospital she has been a constant 
sufferer. The pain in her head has never left her; it is principally 
seated over both her eyes, and over the left in particular. For three 
years she has observed that this pain is aggravated for a fortnight be- 
fore her monthly periodical return; she says she does not know what 
to do, her suffering is so great. The pain varies in a remarkable man- 
ner with the changes of the weather: she knows when rain is approach- 
ing by the increase of the pain, and immediately after it is over the 
pain is relieved. She has not had a return of the loss of speech, or of 
the paralysis of her arm, since she left the hospital, but she has had fits 
and she has suffered from cramps in the back of her neck and right 
breast. The arm, which was formerly paralytic, becomes, about once a 
month, numbed in such a manner that she cannot use her fingers, and 
this is accompanied with great pain. These attacks do not last for more 
than five minutes. She walks quite well. 

"The loss of sensation is principally in the forehead; when pricked 
with a sharp point in any part as high up as the crown of the head, she 
has no feeling; but in the temples, and below the orbits, and on the 
nose, she retains sensation. The left eye is blind; the pupil large and 
immovable; the motions of it are gone; the surface is insensible; it is 
clear, and it remains fixed in the centre of the orbit." 

This woman entered the Middlesex Hospital in October, 1824. In 
the third edition of Sir Charles Bell's work, published in 1844, the fore- 
going particulars are given, and the history is resumed by Mr. Shaw, as 
he observed her in June, 1836. At this time there was no marked 
change, except that, from an inflammation of the right eye, she had lost 
the sight, and had become entirely blind. 

That this case was not one of disease within the orbit is sufficiently 
apparent from a consideration of the symptoms, almost all of which 
point to intra-cranial lesion. The extensive paralysis of motion and of 
sensibility, the epileptic convulsions, the cramps, the aphasia, are so 
many circumstances against the correctness of Sir Charles Bell's diag- 
nosis. That the morbid condition was inflammation of the basilar surface 
of the cerebral membranes is extremely probable, as much so upon the 
principle of exclusion as from a consideration of the positive symptoms. 



238 DISEASES OF THE BRAIN. 

In a case which I saw in consultation with Dr. H. Knapp, of this 
city, the patient, a young man, in whom there was no history or even 
suspicion of syphilis, was attacked with severe pain in the head, at- 
tended with dimness of vision in both eyes. In the next place the 
third pair of nerves became involved, causing paralysis of all the ocu 
lar muscles supplied by these nerves on both sides, and of both eyelids 
and also producing dilatation of both pupils. Next both fourth nerves 
were affected; then the fifth pair causing facial anaesthesia and paralysis 
of the temporal and masseter muscles on both sides; then the sixth, and 
eventually the seventh and eighth, resulting in paralysis of both exter- 
nal recti muscles, double facial paralysis, and loss of hearing in both 
ears. There was, therefore, in this very remarkable case, a gradual ad- 
vance of the morbid process, through a period of several weeks, along 
the base of the brain, from the anterior to the posterior region. With 
all these symptoms there was not the slightest mental derangement; 
neither was there paralysis of any other muscles than of those supplied 
by the nerves specified. Shortly after I saw him the pneumogastric 
nerves became implicated, and death soon ensued. Unfortunately, 
there was no post-mortem examination, but Prof. Knapp and myself 
agreed that the case was one of inflammation of the membranes cover- 
ing the basilar surface of the brain. 

In the case of a woman who came to my clinique in the winter of 
1871-72, the principal symptoms were deep-seated pains in the head, 
vertigo, and paralysis of the third nerve on the left side, as evidenced 
By ptosis, dilatation of the pupil, and external strabismus, the latter 
condition producing diplopia. Conjoined with these symptoms there 
was slight but decided paralysis of the muscles of the face, arm, and leg 
of the. opposite side, together with cutaneous anaesthesia. Inquiry 
showed that these symptoms had been of very gradual development. 
There was no history of syphilis in the case. I was of the opinion that 
the disease was chronic basilar meningitis, and gave an unfavorable 
prognosis; prescribing, however, the iodide of potassium in large doses. 

The following year she returned, but this time the sixth nerve was 
affected, causing internal strabismus; and the ptosis, paralysis of the in- 
ternal rectus, and the dilatation of the pupil, had entirely disappeared. 
The other symptoms had for a time been very greatly relieved by the 
treatment, but had reappeared in considerable intensity about two 
months previously. 

In another instance, this migratory character of the disease was 
well shown. The case was that of a young man, a private patient, but 
whom I showed to the class attending my clinique. He came to me 
originally with external strabismus, ptosis, and dilatation of the pupil 
of the left eye, together with defective accommodation. Examination 
with the ophthalmoscope showed the existence of optic neuritis, rather 
slight in character, but yet decided, in both eyes. He had also the most 



CHRONIC CEREBRAL MENINGITIS. 239 

intensely agonizing pain in the head that has ever come under my ob- 
servation, with vertigo, frequent attacks of vomiting, and paresis if 
not paralysis of the left arm and leg. A consideration of his condition 
led me to the diagnosis of a cerebral tumor, and I accordingly gave a 
very unfavorable prognosis. I was led to this conclusion not so much 
from the motorial derangement, as from the atrocious cephalalgia from 
which the patient suffered. In this case there was some slight suspi- 
cion of syphilis, and I treated him with mercury and large doses of the 
iodide of potassium. In a short time the pain in his head disappeared, 
and in a few weeks there were no indications of paralysis anywhere; in 
fact, he was to all appearances perfectly cured. But at the end of two 
or three months he reappeared, with the corresponding set of symptoms 
in the right eye and right side of the body, and with pain in the head 
fully as severe as that which had characterized the previous attack. I 
again treated him with mercury and the iodide of potassium, and his 
symptoms again disappeared. He remained well for two years, when 
he had another attack, of which he was entirely relieved by the iodide 
of potassium. 

In this case, the history of which points strongly to a syphilitic 
origin, there were probably inflammation and thickening of the mem- 
branes at the base of the brain, and presumably gummy formations. 

The fact that the inflammation sometimes alternates with skin-erup- 
tions is interesting, and has been repeatedly noted. A case of the 
kind was not long since under my care. It was that of a gentleman 
who had attacks of acute pain in the head, accompanied with all the 
phenomena of paralysis of the left third nerve. There was effusion of 
lymph upon both optic disks, the result probably of old optic neuritis. 
Curiously enough, these attacks alternated with an eczematous affec- 
tion, involving the trunk and especially the breast. On the disappear- 
ance of the skin-disease under remedial measures, his head-symptoms 
immediately recurred, and, when they were relieved by the action of the 
iodide of potassium, he was again attacked with eczema. 

Of the forty-seven cases of basilar meningitis collected by Gintrac, 1 
several of them were distinctly chronic in character. As post-mortem 
examinations were made in these cases, they will be more appropriately 
considered under the head of morbid anatomy and pathology. 

Causes. — The causes of chronic basilar meningitis are generally 
sufficiently apparent. It may result from an acute attack, but this 
is not a usual mode of origin, for the reason already stated, that death 
is ordinarily the consequence of such an affection. The most common 
cause in my experience is syphilis; next, the inordinate use of alcoholic 
liquors ; and next excessive emotional disturbance, such for instance as 
business anxieties. Then next in point of frequency come atmospheric 
vicissitudes, blows on the head, and attacks of other diseases, as scarlet 
1 Op. cit., tome ii., p. 677. 



240 DISEASES OF THE BRAIN. 

fever, and especially epidemic cerebro-spinal meningitis, and suppura- 
tive otitis. Men are more subject to it than women, and adults more 
than children. Frequently no cause can be assigned. 

Diagnosis. — Chronic basilar meningitis is not liable to be con- 
founded with any other cerebral affection except tumors, especially 
those of a syphilitic character, situated at the base of the brain, and 
chronic softening, arising from thrombosis of the basilar arteries, and 
diseases of the capillaries. 

From non-syphilitic tumors it, may be distinguished by the fact that 
the paralysis is less extensive, that the pain is not usually so severe, 
that the vertigo is not so intense or persistent, and that the dis- 
turbances of vision are not so profound. In a word, the symptoms of 
chronic basilar meningitis are less pronounced than those of tumors at 
the base of the brain, while at the same time they are ordinarily de- 
veloped with greater rapidity. Another mark of difference is the fact 
that tumors, non-syphilitic in character, do not yield to remedial meas- 
ures, while chronic basilar meningitis often does, and is generally miti- 
gated by proper treatment. 

From tumors of a syphilitic nature, or gummata, as they are called, 
the diagnosis is difficult, if in fact there is any real distinction existing 
between them and basilar meningitis of syphilitic origin. A gummy 
tumor situated at the base of the brain can scarcely exist without the 
production of basilar meningitis, so that the symptoms such as have 
been described, present in a person having the clinical history of syphi- 
lis, are either the result of simple chronic meningitis, or of meningitis, 
associated with one or more gummy tumors. Virchow 1 goes so far as to 
doubt if even, where after death we find only meningitis, the condition 
has not been preceded by a gummatous affection which has disappeared. 
The further consideration of this point will be more proper under the 
head of morbid anatomy. 

Where there is no history of syphilis, of course the question of the 
existence or non-existence of syphilitic tumors will not arise. 

From thrombosis of the arteries at the base of the brain, and from 
such diseases of the capillaries in the same situation as have been de- 
scribed in the previous chapter, chronic basilar meningitis is scarcely 
distinguishable during the life of the patient. When these are syphi- 
litic in character, the two conditions generally coexist. Sooner or 
later, however, the former affections terminate in death, and the phe- 
nomena to which they give rise, though sometimes remitting in violence, 
are clearly not lessened in severity by medical treatment. As regards 
other affections, the history of the case will generally be a sufficient 
guide to a correct diagnosis. 

Prognosis. — The prognosis is very much influenced by the etiology. 
Those cases which result from injuries generally terminate fatally, as do 
1 "Pathologie des tumeurs, traduit de l'Allemand," Paris, 1869, tome ii., p. 440. 



CHRONIC CEREBRAL MENINGITIS. 241 

those due to the excessive use of alcoholic liquors, especially if the habit 
be continued. When induced by mental influences the prognosis is 
generally more favorable, provided the patient can be subjected to the 
hygienic operation of rest, travel, change of associations, etc. Syphilitic 
basilar meningitis, if seen sufficiently early and subjected to proper 
treatment, usually terminates in recovery. Subsequent attacks, which 
are always liable to occur, do not in general run so favorable a course. 
In all cases a great deal depends upon the duration of the disease- 
When of long standing the morbid changes in the tissues involved have 
usually become so profound that recovery is not a probable sequence. 

The age of the patient is likewise an important point in the prog 
nosis ; and, other things being equal, individuals of advanced years are 
not so apt to recover as those of middle life. In children a fatal termi- 
nation is to be expected. 

Those cases which are due to the extension of inflammation from the 
ear almost invariably end in death, as do those ensuing upon epidemic 
cerebro-spinal meningitis. Latterly, however, I have had under my 
charge two cases, resulting from cerebro-spinal meningitis, in which it 
has taken place, though with very marked impairment of vision from 
double optic neuritis in both, and of hearing in one. 

Morbid Anatomy. — The morbid anatomy of chronic basilar menin- 
gitis does not differ in many respects from the corresponding affection 
of the convex surface of the brain. It is, however, generally much 
more circumscribed in its extent, and may be restricted to a portion of 
the membranes not larger than a dime in circumference. In one form 
the affected tissues are thickened and opaque, and there is an exudation 
of serous or gelatiniform fluid ; in another the exudation is puriform ; 
and in a third it is thick and gummy, constituting the so-called gummy 
tumor of syphilitic origin. 

The serous or gelatiniform exudation often shows a tendency to be- 
come organized and to present a membranif orm appearance, or even to 
assume a still more solid form. Gintrac cites from Simon 1 the case of a 
woman, thirty-five years old, who for six years had been subject to 
paroxysms of intense cephalalgia. Two years subsequently she became 
blind on the left side, and for two months afterward suffered still more 
severely from pain in the head ; then she lost the sight of her right eye. 
Both irides remained contractile. The sense of smell was lost, though 
the pituitary membrane retained its tactile sensibility. Hearing, taste, 
and touch, were unaffected. Coma supervened, in which she died. On 
examination, the diploe and the membranes were found congested. 
The arachnoid and the ventricles contained an excess of serous exuda- 
tion. In the pia mater there was a deposit of a whitish-gray fibrinous 
substance which followed the course of the middle cerebral vessels, and 
lay over the chiasma of the optic nerves, the tubercula mammillaria, and 

1 "Bulletin de la societe anatomique," 1845, p. 196. 



242 DISEASES OF THE BRAIN. 

the anterior perforated spaces. The optic and olfactory nerves were 
atrophied and the chiasma deformed ; the retinse were normal. 

Usually the membranes are, in some places, firmly adherent to 
each other, and not infrequently to the cortical substance of the 
brain, in which case the latter is softened to such an extent as 
to tear away when the attempt is made to separate the membranes 
from it. 

When the exudation is puriform in character it occasionally be- 
comes thick, and appears as semi-solidified plates in various situations. 

The exudation, whatever its nature, may be deposited between the 
layers of the arachnoid, in the sub-arachnoid space, or in the meshes 
of the pia mater. Its seat may be any part of the base of the brain, 
but its usual situations are the chiasma of the optic nerves, along 
the course of these nerves, on the tuber cinereum, the corpora mam- 
millaria, and between the crura cerebri. Sometimes it extends anteri- 
orly along the course of the olfactory nerves, laterally into the fissure 
of Sylvius, and posteriorly as far as the pons Varolii and medulla 
oblongata. 

In the syphilitic form of the disease it is a matter of some doubt 
whether the gummy exudation is the result of the specific inflamma- 
tion of the membranes or whether the inflammation is excited by the 
presence of the new formation. Gintrac l seems inclined to doubt 
the existence of syphilitic meningitis, though he admits the possi- 
bility of its occurrence. For him there is no syphilitic meningitis un- 
less its presence be demonstrated by a post-mortem examination and 
its characteristics definitely established, while others give a specific 
nature to any inflammation of the meninges — and, in fact, to any 
other affection — occurring in a person who at any time has been the 
subject of syphilis. In my opinion, cerebral meningitis may be in- 
duced by the syphilitic diathesis, and thus be a syphilitic meningitis, 
and it may exist as a non-specific affection in an individual who has 
had an infecting chancre. Undoubtedly there are cases of meningitis 
occurring in syphilitic persons that are no more under the influence 
of anti-syphilitic treatment than the cases happening in otherwise 
healthy individuals. Fox, 2 however, states it as his opinion that it is 
at best an open question w T hether meningitis ever occurs indepen- 
dently of syphilis, rheumatism, alcoholic poisoning, tubercle, anemia, 
or mechanical irritations. 

But, in regard to the morbid anatomy of chronic basilar menin- 
gitis of syphilitic etiology, Virchow 3 has supplied very important 
data in his remarks on syphilitic tumors of the brain and its mem* 
branes. 

1 Op. cit, tome iii., p. 100. 

2 "The Pathological Anatomy of the Nervous Centres," London, 1874, p. 65. 

3 Op. cit, p. 437 el seq. 



CHRONIC CEREBRAL ilEXIXGITIS. 243 

The gummy tumors are seen most frequently at the base of the brain. 
Sometimes they are very exactly defined in their boundaries, and then 
they are tumors in the true sense of the word ; but ordinarily they are 
more diffused, and are accompanied with the phenomena of inflamma- 
tion, a fact which seems to distinguish them from the true tumor. As 
already stated, Virchow regards this condition as a " gummy inflamma- 
tion ; " and even when the exudation is not present, and the appear- 
ances are those of a non-specific inflammation of the membranes, the 
question may arise whether or not the gummy exudation has not been 
the first step in the morbid process, but, having been absorbed, has left 
only doubtful traces of its presence. With the true gummy tumor we 
are not at present concerned. 

The most common seat of syphilitic basilar meningitis is the region 
bounded anteriorly by the chiasma of the optic nerves, and posteriorly 
by the crura of the cerebellum. Hence it is that the nerves lying at the 
base of the brain, and especially the third pair, are so liable to be im- 
plicated. This latter, from its exposed situation, running as it does 
from the crura cerebri to the orbit, can scarcely escape being involved 
in the morbid process. 

Pathology. — The functions of the nerves at the base of the brain are 
so well understood that the connection of the symptoms of chronic 
basilar meningitis with the morbid condition constituting the disease is 
sufficiently apparent in the great majority of cases. The circumscribed 
character of the inflammation enables us also to determine its seat with 
accuracy, and its migrations can be marked with considerable certainty. 
Probably in the very earliest stage of the disease these points cannot 
always be clearly made out, for the principal phenomenon is centric 
pain, due to congestion, and it is difficult to locate the seat with exact- 
ness ; but, as the affection advances to its full development, effusion 
takes place, and then the eccentric symptoms become more prominent 
if they do not at this time make their appearance. These we have seen 
consist of disturbances of sensibility and of motility in those parts of 
the body supplied by the nerves at the base of the brain, or of aphasia 
from the extension of the inflammation along the fissure of Sylvius to 
the island of Reil, or parts of the brain in its immediate vicinity. It is 
only at a still later period, when the morbid process has directly or in- 
directly involved the crura cerebri, or has spread to the convexity of 
the brain, that sensibility or motility is disturbed in the trunk and 
limbs. 

When the sense of smell is deranged, the lesion exists upon the 
same side as the symptoms, for, as we know, the olfactory nerves do 
not decussate. 

When vision is impaired from optic neuritis, we cannot be so sure 
as to the side upon which the disease exists. For we may have optic 
neuritis as che consequence of disease in distant parts of the brain, as 



244 DISEASES OF THE BRALtf. 

well as from the direct implication of the optic nerves in the patho- 
logical condition ; and even when this latter is the case, owing to the 
incomplete decussation of these nerves, it is possible for optic neuritis 
to exist in conjunction with a homolateral or a hetcrolateral lesion. 

The symptoms due to the involution of the third pair of nerves are 
manifested as regards the upper eyelid, which becomes paralyzed and 
drops over the eye, the muscles of the globe, except the external rectus, 
and the pupil, which is dilated, owing to the paralysis of the circular 
fibres of the iris, which receive their motor influence, through the third 
nerve, from the ophthalmic ganglion. 

The third pair of nerves have their apparent origin in the crura 
cerebri, the right nerve from the right crus, and the left nerve from 
the left crus. If, however, the fibres be followed out by minute dis- 
section, it will be seen that their true origin is from a large nucleus 
situated in the ventral portion of the gray matter surrounding the 
aqueduct of Sylvius. This nucleus is composed of a number of groups 
of cells, each one of these groups supplying a different ocular muscle. 
Each nucleus of one side innervates the ocular muscles on the same 
side with one exception. According to Spitzka, 1 it is demonstrated 
that in animals with conjugated lateral eye movements the origin of 
each third nerve is not limited to the nidi of its side ; a part is decus- 
sated, and the decussated origin is related to the innervation of the in- 
ternal rectus. This decussation occurs within the pes ; therefore each 
nerve, at its exit from the pes, contains its full complement of fibres. 
The pes also contains the motor and sensory fibres which supply the 
opposite side of the body. Disease involving one pes would, therefore 
cause derangement of motility in the muscles supplied by the corre- 
sponding third nerve, and of sensation and motion in the opposite 
half of the body ; alternate or cross-paralysis would therefore be the 
result. As chronic basilar meningitis often involves the membrane 
covering a pes, cross-paralysis is frequently a phenomenon of the 
disease. 

In those cases in which there is no paralysis anywhere except in 
the muscles supplied by the ocular motor nerve, the lesion must exist 
anteriorly to the pes, and affect the trunk of the nerve of the same 
side as that of the paralyzed muscles. 

It is not often the case that the fourth nerve, or trochlearis, is alone 
involved, though one such case has come under my observation. In 
this the patient had no marked symptom of any kind, except that in a 
certain position of his head he saw double. On examination, I ascer- 
tained that, when he turned his head toward the left shoulder, he saw 
double, and hence I diagnosticated paralysis of the left superior oblique 
muscle. Further experiments confirmed this opinion, and the diagnosis 
of chronic basilar meningitis was shown to be correct by the extension 
1 " Histology of the Brain." Kef. " Handb. Med. Scien.," vol. viii., 1889. 



CHRONIC CEREBRAL MENINGITIS. 245 

of the disease so as to involve the third nerve, and by the supervention 
ol pain and other phenomena of the affection in question. 

The sixth nerve, or abducens, is not infrequently the only nerve 
implicated in the lesion, and then there is internal strabismus from 
paralysis of the external rectus muscle. Several such cases, in which 
there were the concomitant symptoms of chronic basilar meningitis, 
have come under my notice. The case of one of these, a woman, who 
formed the subject of a clinical lecture, has already been cited. An- 
other case was that of a man, the subject of syphilis, and in whom the 
lesion was only manifested as regarded the external rectus muscle. 
There were no head-symptoms of any kind. The paralysis had ensued 
during the night, and the patient awoke in the morning to find that he 
had internal strabismus and double vision. He recovered entirely under 
the use of large doses of the iodide of potassium. But on the 10th of 
January, 1875, he had an epileptiform paroxysm, and this was several 
times repeated during the following week. Under the influence of the 
iodide of potassium, conjoined with the bromide, he has for the past two 
months had no return of. the convulsions ; but his mind is somewhat 
confused, and he has occasional severe pain in the head. 

The seventh, or facial nerve, is sometimes embraced in the morbid 
process, giving rise to paralysis of one or more of the muscles on one 
side of the face, which it supplies. In one instance, apparently the re- 
sult of syphilitic basilar meningitis, which came under my charge in 
December, 1874, both facial nerves were involved, and there was conse- 
quently double facial paralysis. 

The eighth, or auditory nerve, also occasionally gives evidence of 
loss or impairment of its function; but, unless special examination rela- 
tive to the hearing be made, or both nerves be involved, the lesion, as 
regards this nerve, may escape detection, as patients very often, even 
when the hearing is entirely destroyed in one ear, are unaware of the 
fact, and persist that it is unimpaired. 

The ninth, tenth, and eleventh pairs of nerves are not so apt to be 
affected in chronic basilar meningitis as some of the others, for the rea- 
sons that their relations with the interior of the cranium are not so in- 
timate, and that the seat of the disease is generally anterior to their 
situation. 

Should the ninth, or glosso-pharyngeal nerve, be involved, there 
would be loss or impairment of the sense of taste upon the corre- 
sponding side, and the implication of the pneumogastric would lead to 
a complicated series of phenomena, of which the chief would be pal- 
pitation of the heart, irregularity of the respiration, and derangement 
of the function of digestion; while, if the spinal accessory were reached 
by the morbid process, there would be difficulty of swallowing, and 
perhaps alteration in the timbre of the voice. 

The hypoglossal, or sublingual nerve, is occasionally affected, pro- 



246 DISEASES OF THE BRAIN. 

ducing paralysis of the side of the tongue corresponding to the situa- 
tion of the disease. 

When the fifth nerve is involved, the chief manifestations of its 
lesion are relative to sensation. Thus there are either intense neuralgic 
pains in some part of the cutaneous surface of the head or neck, or 
there is equally well-marked ansesthesia. The former condition is by 
far the more frequent. From some cause or other, the motor fibres of 
this nerve almost invariably escape, and thus the temporal and masseter 
muscles are not paralyzed. I have, however, already cited a case in 
which they were affected. 

The general relation of the symptoms of chronic basilar meningitis 
with the lesion constituting the disease is well shown in several of the 
cases cited by Gintrac. Thus he quotes one from Bossu, 1 that of a 
man, twenty-four years old, who from exposure became affected with 
headache about the supra-orbital region, vertigo, noises in the ears, 
facial neuralgia, and muscular contractions. At the end of a year he 
had vomiting, want of appetite, general debility, and a continuation of 
the supra-orbital headache. There were also amblyopia, diplopia, ex- 
ternal strabismus, dilatation of the pupils, and painful contractions of 
the right side of the face. The pulse was full, regular, and not fre- 
quent; the mind was unaffected. Coma supervened, the right side of the 
face became insensible, the evacuations were involuntary, speech was 
impossible, and the movements of the tongue were imperfectly per- 
formed. The pulse was feeble and frequent, and death ensued. On 
post-mortem examination, a reddish serum was found to be infiltrated 
between the convolutions. At the base, under the third ventricle, a 
gelatiniform substance enveloped the commissure of the optic nerves 
and the tuber cinereum. It was reddish in color, and was closely ad- 
herent to the pituitary gland. The tubercula mammillaria were sepa- 
rated by a reddish mass, which extended into the ventricle, and which 
there had the size and form of a nut. 

The following case, cited by Gintrac 2 from Simon, is equally inter- 
esting : 

" A woman, thirty-five years old. For six years accessions of pain 
in the head. Two years afterward blindness of the left eye, and then 
for two months the most intense cephalalgia, followed by loss of sight 
in the right eye. Pupils still active. Anosmia, although the pituitary 
membrane preserved its tactile sensibility. Hearing, touch, and taste 
unimpaired. Skin warm; pulse freqnent, hard, and small. Failure of 
appetite; thirst, constipation, coma, death. 

"There was congestion of the diplfte and of the meninges. The 
arachnoid and the lateral ventricles contained serum. There was a 
grayish-white deposit, of fibrinous appearance, in the pia mater, along 

1 Gazette mediaale de Lyons et moniteur des hopitaux, 1855, p. 853. 

2 "Bulletin de la societe anatomique," I860, p. 143. 



CHRONIC CEREBRAL MENINGITIS. 247 

the course of the middle cerebral vessels, on the chiasm a of the optic 
nerves, the tubercula mammillaria, and the anterior perforated spaces. 
The olfactory and optic nerves were atrophied, and the chiasma was de- 
formed. The retime were normal. The tissue of the brain at the base 
was superficially softened." 

Treatment. — The principles which have been laid down for the man- 
agement of cases of chronic verticalar meningitis are equally applicable 
to the basilar form of the disease. The iodide of potassium, conjoined 
with some one of the bromides, should be administered; and, in syphi- 
litic cases, the former should be pushed to its extreme limit by gradu- 
ally increasing the doses. At the same time, there are other means of 
treatment, which are rendered necessary by the existence of paralysis, 
and these ordinarily consist of strychnia and some form of electricity. 
The details will, perhaps, be more clearly shown by the citation of a 
few cases from my note-book: 

A. W., married, aged thirty-two, consulted me, April 7, 1873, for 
pain in the head, accompanied by paralysis of the third nerve on the 
left side, producing ptosis, external strabismus, dilatation of the pupil, 
and double vision. On examination with the ophthalmoscope, both 
optic papillae were found to be congested, the left far more so, how- 
ever, than the right. He had had an epileptiform convulsion about 
two weeks before coming to me, and had suffered very often from at- 
tacks of vertigo. The first evidence of the disease was the cephalalgia, 
which had been very gradually developed during six or seven months, 
and which was mainly confined to the left temporal region. The pa- 
ralysis of the third nerve had been suddenly produced, on the morning 
of the 1st of April, while he was eating his breakfast. 

There was not the least evidence of syphilis in this case. The af- 
fection had obviously originated from long-continued anxiety of mind, 
the consequence of business troubles. 

I immediately began the administration of the iodide of potassium 
in the form of the saturated solution, in doses of ten drops three times 
a day, increased to twelve drops the second day, fourteen the third, 
and so on. After the fourth day, the intense pain in the head began 
to diminish; and on the tenth day, when the patient was taking thirty 
drops — equivalent to thirty grains — three times daily, it entirely disap- 
peared. The paralysis of the third nerve, however, continued, although 
*he doses of the iodide were carried up to over two hundred grains 
daily, or seventy grains at a dose. The medicine was then discon- 
tinued, and the patient was treated with gradually-increasing doses of 
strychnia, and the interrupted primary or galvanic current applied to 
the closed eye, as nearly as possible over the internal rectus muscle 
on the upper eyelid. This treatment was persevered with for several 
weeks, without any marked effect upon the paralysis of the upper eye- 
lid, though the internal rectus muscle gradually recovered its power, 



248 DISEASES OF THE BRAIN. 

and the diplopia disappeared. Nearly a year afterward, when I again 
saw the patient, the lid still drooped; but there had been no return oi 
the other symptoms. 

A gentleman, aged about fifty, single, consulted me on the 11th of 
August, 1874, for intense pain in the right side of the head, with 
which he had suffered for several months, night and day. Upon exam- 
ination, I discovered that he had experienced an attack of iritis of the 
left eye ten years previously, and that there was other evidence of 
syphilis. There was paralysis of the internal rectus of that side, which 
caused strabismus, though no diplopia, as the sight of the eye had been 
<bst by extension of the inflammation to the capsule of the lens, causing 
opacity. In conversation with him, I observed that he was deaf in the 
right ear, a fact which he had not noticed till his attention was called 
to it and the hearing capacity tested. On examining the ear with the 
speculum, I perceived that the external auditory canal was closed by a 
growth of some kind, which was adherent to the anterior wall. The 
ophthalmoscope revealed the existence of marked optic neuritis of the 
right eye, and the patient could not read No. 3 of Galezowski. No ex- 
amination could be made of the left eye. 

On the following day, when he made his visit to me, the right side 
of his face was paralyzed, as was also the right side of the tongue, and 
his speech was, in consequence, rendered very difficult and indistinct. 
I then began the administration of the iodide of potassium, in the form 
of the saturated solution, starting with the dose of ten drops three 
times a day, and directing it to be gradually increased. This was con- 
tinued till the 14th, when I removed the growth from the ear, by ex- 
cision, with a delicate bistoury. The effect of this operation was at 
once evident, so far as the hearing was concerned, and the patient de- 
clared that the pain in the head was decidedly mitigated. As it stilly 
however, continued, I augmented the doses of the iodide by six drops a 
day, instead of three, and began the application of the interrupted 
primary current to the paralyzed muscles of the face and tongue. On 
the 20th he was taking twenty-one grains three times a day. The pain 
was decidedly less ; but, as there were sharp lancinating pains along the 
course of the auricular branch of the lesser occipital nerve, I made an 
incision through the scalp, so as to divide it. . The effect was, to abolish 
this pain altogether. The intra-cranial pain gradually diminished 
under the increasing doses of the iodide, and on the 27th of August had 
entirely ceased. The medicine was continued for several days after- 
ward, and was then omitted. The tongue gradually improved in motor 
power ; but several months subsequently was not protruded straight, 
although the speech was as good as ever. There has been no return of 
the other symptoms. 

The growth removed from the ear was examined microscopically by 
my friends Prof. Roosa and T. E. Clark, as well as by myself, and we 



CIIRONIC CEREBRAL MENINGITIS. 249 

agreed in the opinion that it was neuromatous in character. The whole 
tumor was somewhat larger than a large pea. 

The following very interesting case, which occurred recently in my 
practice, I quote from Dr. Lente's excellent paper " On the Neurotic 
Origin of Disease," 1 read before the New York Neurological Society, 
December 7, 1874. Dr. Lente had frequent opportunities of seeing 
this patient in my consulting-room, and of witnessing the results of the 
treatment. Mr. W. was also kind enough to allow me to present him 
at my clinique at the Medical Department of the University of New 
York, and to describe his case to the class in attendance. 

" The treatment of the following case I had the opportunity of 
watching, through the courtesy of Prof. Hammond. The history I had 
from the patient himself: 

" Mr. W., a grain-inspector of Chicago, was attacked three years 
ago with epileptic convulsions; has had them once a month or oftener; 
also some threatening cerebral symptoms; had no treatment that he 
knows of except moderate doses of bromide of potassium and chloro- 
form inhalation. In June last he had a recurrence of cerebral symp- 
toms, insomnia, pain, double vision, etc. This lasted two weeks, and 
disappeared. On the 14th July, after some exposure to the sun, he 
was again attacked with the above symptoms, to a greater degree, and 
with complete inability to raise the eyeball or upper eyelid (left eye), 
also extreme internal strabismus, diplopia, and severe cephalalgia. 
These symptoms occurred suddenly in the night. Could neither read, 
nor distinguish the quality of grain. The strabismus disappeared 
slowly, and the ptosis also diminished somewhat, so that when he ap- 
plied to Dr. H., about the 13th of October, 1874, he could, by an effort, 
raise the lid so as to expose the cornea, but it fell back immediately; 
other symptoms the same. He was put upon increasing doses of the 
iodide of potassium, with the idea of relieving the basilar meningitis, 
presumed to be the cause of the symptoms, the application of the 
induced current to the brow and temple, and the hypodermic injection 
of strychnia. No immediate effect could be expected from the first two 
remedies ; it is to the last that I desire to direct attention. Prof. Ham- 
mond proposed to inject the solution 'directly into the affected muscles, 
and accordingly did so, using gr. -^ in two drops of water; it is pre- 
sumed that it passed into the muscle, or most likely in its immediate 
proximity. In all, six injections, I think, were used. I watched the 
effect carefully and tested the eye and lid after each. They were done 
each alternate day. He declared that he perceived quite a decided ef- 
fect. After the second there was no doubt, as I could see the change 
within fifteen minutes, both on the ball and on the lid, but especially 
on the latter; after the third, the ptosis had entirely disappeared, and 
he could raise the ball to an horizontal plane; the diplopia had disap- 
1 Psychological and Medico-Legal Journal, February, 1815 ; p. 82. 



250 DISEASES OF THE BRAIN. 

peared, and he could read by holding the book low. After the fifth in- 
jection (gr. T^j-) no difference in the appearance of the eyes was distin- 
guishable, and he could read with the book held directly before him. 
He considered himself cured." 

In this case the iodide was carried to doses of sixty grains three 
times a day, before the pain began to yield; and eighty grains, equal to 
two hundred and forty grains daily, was reached, and continued for 
several days, before it was deemed advisable to omit its use. 

Mr. B. was sent to me, December 19, 1874, by Prof. M. A. Pallen. 
At the time he was suffering from agonizing pain in the left side of the 
head, paresis of the whole right side of the body, except the face, apha- 
sia, of the amnesic variety mainly, although the power to coordinate the 
muscles of articulation was greatly impaired, and from decided mental 
disturbance, characterized by the existence of hallucinations and marked 
dementia. The sight of both eyes was weakened, and examination with 
the ophthalmoscope showed the existence of double optic neuritis. 
There was a clear history of syphilis. 

I immediately began the administration of the iodide of potassium, 
in ten-grain doses, three times a day, gradually increased, as in the fore- 
going cases. By the time twenty-grain doses were reached the pain in 
the head had disappeared, the speech was much improved, the weakness 
of the right side had diminished, and the mind was altogether stronger. 
The iodide was continued up to sixty-grain doses, and then, as the 
patient was apparently cured, it was omitted, and he resumed his duties 
as cashier in a bank. 

Two months afterward, he had a relapse into his former condition. 
The accession was sudden. He awoke in the morning with pain in the 
head, weakness of the right side, and complete loss of speech. His 
aphasia was removed by a single application of the galvanic current 
from ten cells to the tongue, and I increased the use of the iodide as be 
fore. He again recovered his health. He is now (March 23d) quite well. 

It would be very easy to adduce many other cases from my private 
and hospital practice, but the foregoing are sufficient to indicate the 
main principles of treatment in chronic basilar meningitis. Occasion- 
ally, in cases of syphilitic origin, in which the infection has been recent, 
it may be advisable to administer mercury in some one of its forms. 
The bichloride, in the dose of the one-sixteenth of a grain, may be given 
with each dose of the iodide of potassium, or the biniodide in like 
doses, in the form of pill. Whether the affection has a syphilitic origin 
or not, antiphlogistic measures, as they are called, are not proper. On 
the contrary, wine and highly-nutritious food are frequently productive 
of amelioration. 

Should insomnia be present, some one of the bromides should be 
given, in doses of from fifteen to thirty grains, three times a day, till its 
full effect be produced. 



TUBERCULAR CEREBRAL MENINGITIS. 251 

It may be stated that I have never observed any ill effects follow 
the administration of the very large doses of the iodide of potassium 
which I have recommended. Coryza is certainly not more apt to occur 
than with the small doses, nor is it more severe. Gastric irritation can 
generally be prevented by diluting each dose in a sufficient quantity of 
water. A dose of fifty or sixty grains should never be taken in less 
than half a tumbler of water. 

In the treatment of the paralysis which often remains, even after all 
active disease within the cranium has disappeared, electricity is almost 
indispensable; and I am entirely satisfied that the hypodermic injection 
of strychnia into the paralyzed muscle, or as near as may be to it, is a 
measure of the utmost importance. The good effects of it were very 
clearly seen in one of the cases cited. 



CHAPTER X. 

TUBERCULAR CEREBRAL MENINGITIS. 

Inflammation of the membranes of the brain, attended with or due 
to a deposit of miliary tubercles, was for many years considered as a 
disease peculiar to infancy, and was known as acute hydrocephalus be- 
fore its morbid anatomy and pathology were clearly comprehended. It 
is now well understood to be an affection to which adults are liable. 

By some authors, especially Robin and Bouchut, it is regarded as 
not being tubercular in character. It has hence occasionally been 
termed granular meningitis. Although mentioned by the ancient medi- 
cal writers, no clear and systematic description of tubercular meningitis 
was given till Whytt 1 published his essay on the subject of dropsy of 
the brain. Since that time it has received the attention of many writers 
in this country, Great Britain, France, and Germany. 

Symptoms. — Whytt defined three periods of the disease, which he 
marked by the state of the pulse. I think the symptoms may be prop- 
erly arranged in four stages: 1. The prodromatic stage; 2. The stage 
of excitement; 3. The stage of depression; and 4. The stage of recur- 
rence. 

1. The Prodromatic Stage. — This period may be altogether want- 
ing, or may be so slightly manifested as not to be noticed. Generally, 
however, it is well marked. 

If the child be sufficiently advanced in years, a change of disposition 
is among the first symptoms perceived. Thus the temper becomes irri- 

1 " Observations on the most Frequent Form of the Hydrocephalus Internus, viz., 
Dropsy of the Ventricles of the Brain. Works of Robert Whytt, edited by his Son. ,; 
Edinburgh, 1768, p. 725. 



252 DISEASES OF THE BRAIN. 

table, caresses are disregarded, and dislike is shown for those amuse- 
ments which formerly gave pleasure. At the same time the appetite 
disappears, and the child loses flesh rapidly. This latter is not noticed 
about the face, but is mainly confined to the abdomen and limbs. The 
bowels are generally obstinately constipated, but occasionally there is 
diarrhoea. Headache is not often complained of; neither is vomiting a 
common symptom of this period. Fever is not continuous, although it 
is generally present at irregular times of the day. 

The prodromatic stage may last only a few days, or may be pro- 
longed for two or three months. 

2. The Stage op Excitement. — This period is ushered in by obsti- 
nate vomiting, which is present in many cases, even though no food be 
taken. Intense pain in the head is a coincident symptom, and is so 
severe that the child puts his hands to his head and cries out or awakes 
screaming. Convulsions may also occur. They do not differ in gen- 
eral appearance from the ordinary epileptic paroxysms, and may be re- 
peated several times. 

Very earl^ in this stage the fever becomes more persistent than in 
the first stage, although it may still be irregular. The pulse, however, 
is not hard and resisting, as in other inflammatory affections, but is soft 
and compressible. 

Trousseau 1 has called attention to a condition of the skin present in 
tubercular meningitis, which he at first regarded as peculiar to this dis- 
ease, but which subsequent investigation showed was likewise found in 
simple meningitis, in typhoid fever, and some other affections. If the 
finger-nail be passed lightly over the surface of the abdomen or the 
thorax so as to trace a series of lines, in about thirty seconds the skin 
becomes red — the color being at first diffused, but very soon the lines 
made by the nail are indicated by a still redder color, which persists a 
long time. Trousseau calls this appearance the " cerebral stain " (tache 
c&rbbrale). The phenomenon he attributes to a profound modification 
in the vascularization of the skin; and, although it is not to be regarded 
as absolutely pathognomonic, it is a sign of very great importance. 

The intellectual faculties are not yet affected to any considerable 
extent, but the changes of character and disposition, and indifference to 
things which formerly excited interest, are still well marked. 

The physical strength, though lessened, is still not yet so far re- 
duced as to oblige the patient to remain in bed. 

The tongue is usually coated and red at the edges, the appetite 
diminished, and the bowels are obstinately constipated. 

The temperature of the body is elevated, but not to an extreme de- 
gree; the thermometer indicating from 101° to 103° Fahr. Sometimes 
there are distinct remissions in the violence of all the symptoms, but the 
disease nevertheless goes on to its full development. The transmission 
1 Op. cit, Le9on lv., " Fievre Cerebrale." 



TUBERCULAR CEREBRAL MENINGITIS. 253 

from the second to the third stage is often marked by an amelioration 
which may last several days. 

From what has been said, it will be seen that the characteristic phe- 
nomena of this stage are headache and vomiting. Its duration varies 
from seven to fourteen days. 

3. Stage of Depression. — The pulse, which in the previous stage 
was sometimes as high as 140, and sometimes as low as 80, now becomes 
less rapid than is normal, and may even fall below 50. At the same 
time the beat is quick, but the interval between the pulsations is at 
times so great that the observer is, as Dance x says, fearful that the 
action of the heart has stopped. The interval between the pulsations is 
often irregular, and this may be regarded as a sign of unfavorable im- 
port. 

In young infants there is a reduction in the temperature of the body 
below the normal standard, which lasts throughout the whole of this 
period. Roger regarded this reduction, preceded as it is by a higher 
temperature, and followed during the succeeding stage by another ele- 
vation, as pathognomonic of tubercular meningitis. 

The continued excitement of the previous stage is replaced in this by 
a strong tendency to somnolence, which alternates with a rather quiet 
delirium. The patient lies on. his back, with the eyes fixed, but yet not 
looking at any object with attention. Events taking place around him 
no longer attract notice, and, though when addressed in a loud tone he 
may turn his gaze toward the speaker, it is very evident that the words 
convey no idea to his mind. 

The fingers are kept in almost continual motion, picking up threads 
and other small objects from the bedclothes, and occasionally clutching 
at imaginary things. Again, the fingers are alternately opened and 
shut without any real or apparent motive, and again the head is turned 
restlessly from side to side of the pillow. Convulsions are very gener- 
ally present from time to time during this stage, and may be so fre- 
quently repeated as to leave scarcely any interval between the seizures. 
Even if the attacks do not involve the body generally, the eyes scarcely 
ever escape; there being strabismus, convulsive movements of the 
pupils, and constant motions of the eyeballs. The facial muscles are 
likewise often affected. 

In the intervals of wakefulness, the cephalalgia continues, and 
causes the peculiar scream which is so characteristic as to have received 
the name of the " hydrocephalic cry." It is a sound such as might be 
produced by mingled emotions of terror and grief. Although probably 
excited by the pain, it is more or less automatic, and is not exactly such 
a cry as would be produced by unmixed physical suffering. It is ac* 
companied, however, by that contraction of the muscles of the face in- 
dicative of suffering. 

1 " Memoire sur I'hydrocephale," Archives generate des medecine, 1830. 



254 DISEASES OF THE BRAIN. 

The paleness of the countenance continues, but at times there is a 
sudden redness, which disappears as rapidly as it comes. 

The conjunctivae are generally injected, and photophobia is present. 
M. Bouchut, 1 who has given great attention to the subject of ophthal- 
moscopy in diseases of the nervous system, finds peripapillary con 
gestion, dilatation of the retinal vessels, and deformation of the papillas 

There is often a general hyperesthesia of the skin, for which, how- 
ever, anaesthesia may be substituted. When this latter is the case the 
conjunctive participate, and inflammation results. 

The limbs are weak, and, should the patient attempt to walk, the 
gait is staggering. The speech is hesitating, is rarely indulged in ex- 
cept in response to questions, and then with the least possible expendi- 
ture of words. 

The vomiting, which formed so prominent a symptom of the previous 
stage, has ceased, but the constipation still persists. 

The respiration is irregular, sometimes being rapid and sometimes 
slow. Occasionally there are deep sighs, followed by numerous quick 
inspirations, and again the respiratory movements may be so slight as 
scarcely to be perceived. This variation from the normal action, as 
well as the irregularity of the heart's movements, is due to the implica- 
tion of the pneumogastric nerves at their origins. 

This stage may last for from two or three days to two weeks. 

4. Stage of Recurrence. — The characteristic phenomena of this 
stage are the return of the fever and the increase in the violence of the 
symptoms indicative of cerebral disturbance. Before its onset there 
may be a period of nearly complete intermission, so that the impression 
may be formed that recovery is taking place. This apparent cessation 
of the morbid action, however, only serves, with the experienced ob- 
server, to make the reappearance of the symptoms more striking. 

Convulsions are more frequent and violent than in the previous 
stage, and tonic contractions of the limbs are not uncommon. These 
contractions are more generally met with in the muscles of the neck 
and upper extremities, and vary from time to time in their intensity. 
The head is thus thrown backward, and, as the morbid action frequently 
extends to the muscles of the back, an appearance in the patient not 
unlike that present in tetanus is produced. 

Paralysis eventually supervenes. At first this is incomplete, affect- 
ing only a single limb or the muscles of the face, but it extends, and 
both limbs on one side, or an arm and a leg of opposite sides, become in- 
volved. Voluntary power is lost, but reflex movements can be excited 
by pinching or tickling. 

The delirium acquires increased intensity, and alternates with the 
somnolence, which likewise becomes more profound, and which gradu- 

1 " Du diagnostic des maladies du systeme norveux par rophthalmoscopie," Faria, 
1866, p. 45, et seq. Plates iv., v., vi., vii., viii., ix., and xi., of the Atlas. 



TUBERCULAR CEREBRAL MENINGITIS. 255 

ally masks all the other symptoms, till at last the coma is persistent 
and general, and spinal sensibility is lost. 

Before death the pulse rises in frequency, a cold sweat makes its ap- 
pearance, and the patient dies either by a slow process of asphyxia, or 
in convulsions. 

The fact that tubercular meningitis is not confined to infants is now 
generally admitted. Dance ' was the first to recognize its occurrence in 
adults, and Gerhard, 2 of Philadelphia, a few years subsequently reported 
several cases. Ledibuder 3 also pointed out the analogy between the 
tubercular meningitis of infants and that of adults, and still later Val- 
leix 4 gave the weight of his authority to the same effect. 

So far as the symptoms are concerned, I have never been able to 
perceive any essential points of difference between the tubercular men- 
ingitis of children and that of adults. 

The affection is, of course, modified, as are all other diseases, by the 
age of the patient, but, when allowance is made for this factor, the 
morbid process is one and the same in character. In adults, however, 
it generally supervenes in the course of tuberculosis of the lungs, 
whereas in infants it is ordinarily a primary manifestation of the tuber- 
cular diathesis. 

Causes. — Tubercular meningitis is an expression of a general state 
of the system. To enter at length into the question of its etiology 
would necessarily involve a discussion of the cause of the diathesis to 
which it is essentially due. Nevertheless, there are a number of deter- 
mining causes that may be appropriately considered. Age is an im- 
portant factor in determining the accession of tubercular meningitis. 
It is rare during the first year of infancy, but is more common during 
the period extending from the second to the seventh year than any 
other time of fife. From eight to ten it is much less frequent, and from 
ten to fifteen is rarely seen. 

In adults it is most common between the ages of seventeen and 
thirty. From thirty to forty it is rare, and after forty is scarcely ever 
met with. 

Males are more frequently the subjects of tubercular meningitis than 
females, and this holds good for all ages of life. 

The season of the year appears to exercise no influence. 

As to many other exciting causes alleged by authors, such as blows, 
emotional excitement, and previous diseases, nothing very definite is 
known. The same cannot, however, be said of the morbific influence of 
bad air, insufficient food, improper clothing, neglect of cleanliness, and 
a disregard of other sanitary requirements. 

1 Op. cit. 2 American Journal of the Medical Sciences, 1834. 

3 " Essai sur l'affection tuberculeuse aigue de la pie-mere," Paris, 1837. 

4 " De la meningite tuberculeuse chez l'adult." Archives generales de medecim t 
1838. 



256 DISEASES OF THE BRAIN. 

Diagnosis. — Tubercular meningitis is liable to be confounded with 
several other affections, and can sometimes only be distinguished with 
difficulty. 

From simple meningitis it may be diagnosticated by the facts that 
the onset of the former is sudden, while the latter is insidious in its ap- 
proach, and slow in the development of its symptoms; the one goes on 
steadily through its course, the other halts and remits; in the one the 
temperature of the body rises several degrees, in the other the elevation 
is scarcely ever more than two degrees; in the one there is no hereditary 
tendency, while in the other inquiry will usually reveal the existence of 
hereditary tubercular predisposition. 

The mental symptoms show a marked difference. In simple menin- 
gitis the delirium is often furious, and is always very active; in the 
tubercular form of the disease the delirium is quiet, and alternates with 
stupor. 

In typhoid fever there may be vomiting and headache, but the 
bowels are not constipated, and there is tenderness over the right hypo- 
gastric region. Moreover, the epistaxis, the eruption, and the swelling 
of the spleen, which occur in typhoid fever, will aid in making the diag- 
nosis more certain. 

Worms in the alimentary canal may give rise to a set of symptoms 
very similar to those which form the prodromata of tubercular menin- 
gitis. As Jaccoud observes, therefore, it is well, whenever a child ex- 
hibits these symptoms, to administer one or two doses of a strong ver- 
mifuge. 

A peculiar affection, to which young infants are liable, may be mis- 
taken for tubercular meningitis. It was first described by Dr. Gooch, 1 
but derived its name — " hydrocephaloid disease" — from Dr. Marshall 
Hall. I have already alluded to this disorder under the head of cerebral 
anaemia. In it the child is irritable, restless, starting at every noise, 
moving in sleep, and often waking screaming. Vomiting is frequently 
present, but the bowels are loose. The whole appearance of the child 
betokens exhaustion, and, if due care be not taken, death may ensue. 
The absence of constipation, the history of the case ? and the depressed 
state of the fontanelle, if this be yet open, will suffice to render the 
diagnosis clear. 

Trousseau considers the irregularity of the respiration the most im- 
portant sign indicating the presence of tubercular meningitis. " In no 
other disease," he says, "will you meet with this singular anomaly. 
You will not observe this unequal and irregular respiration either in the 
essential convulsions of infancy or in typhoid fever. I have reason, 
then, for insisting on the importance of the symptoms." 

Prognosis. — There is not much to say under this head. The ordi- 

1 u On Some Symptoms in Children erroneously attributed to Congestion of the Brain." 
Gooch's Essays, New Sydenham Society, 1859, p. 179. 



TUBERCULAR CEREBRAL MENINGITIS. 257 

nary termination of the disease is death. I have never seen a case re- 
cover; and, though instances with a favorable result have been reported, 
I am disposed to think the diagnosis of such has been erroneous. Drs. 
Meigs and Pepper, 1 of thirty-one cases, had no recovery, though they 
report a case of tuberculosis of the meninges — not tubercular menin- 
gitis — in which recovery appears to have taken place, though the child 
died a year or two afterward with dysentery. 

It seems contrary to reason to expect a radical cure in a disease in 
which the cause cannot be removed. Do what we will, the tubercular 
deposit remains; and, as Jaccoud remarks, the reported cases of recov- 
ery were rather instances of a long remission in the intensity of the 
symptoms. Seitz, 2 in his recent treatise, asserts that the time when cases 
of acute hydrocephalus were cured has gone by, and that former ap- 
parent success is to be attributed to false diagnosis. He declares that 
he has never witnessed a case terminate favorably. 

Morbid Anatomy and Pathology. — A question arises at the outset of 

an inquiry relative to the morbid anatomy of tubercular meningitis, 
which refers to the essential character of the disease; and that is, 
whether the gray semi-transparent granulations met with on post- 
mortem examination are tubercles, or whether they are an entirely dis- 
tinct morbid product ? Valleix, Rilliet and Barthez, Barrier, Grisolle, 
Meigs and Pepper, and others, regard them as tubercles. Grisolle ex- 
presses himself clearly on this point. " We have no doubt," he says, 
" that these granulations are tubercles in a rudimentary state; for we 
have many times, in the same subject, followed the morbid product in 
its different phases of evolution from the amorphous condition to the 
fully-developed tubercle." 

On the other hand, Bouchut, basing his conclusions mainly on the 
microscopical observations of Robin, is of the opinion that the granula- 
tions are formed: 1. Of fibro-plastic elements, consisting of free nuclei 
and fusiform cells, and ovoid cells. The nuclei are ovoid or spherical, 
and generally very small, not exceeding 0.008 to 0.009 in. in diameter. 
2. Of a great quantity of granular amorphous homogeneous matter, 
which keeps the other elements strongly united. 3. Of a few vessels 
and fibres of connective tissue. Among all these elements the tubercu- 
lar corpuscles of micrographers are not to be found; and, therefore, the 
disease cannot be regarded as tubercular in character. M. Empis 3 also 
contends that the microscopical analysis shows that the gray granula- 
tions are entirely distinct from tubercle. On the other hand, it is 
alleged — and I am disposed to think with force — that the most which 
the investigations of M. Robin and others in accord with him show, is, 

1 " A Practical Treatise on the Diseases of Children," Philadelphia, 1870, p. 452. 

2 " Die Meningitis Tuberculosa der Erwachsenen." Berlin, 18*75, p. 311. 
* "Traite de la granulie," Paris, 1865. 

13 



258 DISEASES OF THE BRAIN. 

that there is no special characteristic of tubercle which will enable us to 
declare with certainty that it is present, and that it does not possess a 
structure which is the same in all stages of its development. The col- 
lateral evidence goes very far to support the view that the granulations 
are tubercular in character. 

The question which also arises, as to whether the inflammation pre- 
cedes the tubercular deposit, or vice versa, is generally decided in favor 
of the prior appearance of the tubercles. The granulations are met with 
in the course of the vessels of the pia mater. This membrane is always 
more or less inflamed, and is thickened by the infiltration of sanguine- 
ous, serous, plastic, or purulent exudations. The granular or tubercular 
matter is generally deposited at the base of the brain, and in this position 
is doubtless the cause of the derangements of motility which constitute 
so prominent a feature of the disease. Its ordinary seat is along the 
course of the middle meningeal artery and its branches. Sometimes, 
though rarely, it is found on the convexity of the brain. 

The tissue of the brain is not generally much involved, although on 
section the red points, indicative of the situation of blood-vessels, are 
very much increased in number. Occasionally there are small extrava- 
sations of blood found in the gray substance. 

The ventricles are distended by serum, and this is sometimes so great 
in quantity as to cause the rupture of the septum lucidum. The liquid 
is either clear and limpid, milky from the presence of pus-globules, or 
bloody from containing red corpuscles. 

The morbid anatomy of the lungs and other organs, although inter- 
esting in the present connection, need not be dwelt upon; suffice it to 
say that tubercular deposits are always met with in some one or more 
of the viscera and especially in the lungs. 

Treatment. — In regard to a disease so uniformly fatal as tubercular 
meningitis, there is not much to say. The principal advice I have to 
give is, to refrain from blisters, antimonial ointment, leeches, and drastic 
purgatives, which have no other effect than to shorten the life of the 
patient, and to make his existence still more intolerable than it is made 
by disease. Iodide of potassium does less harm, but I have never 
known it do any good. Niemeyer, however, recommends it, and many 
will doubtless continue to employ it on his authority. Seitz, 1 in a work 
of nearly four hundred pages, treating of tubercular meningitis in 
adults, devotes less than two pages to the subject of treatment, and 
speaks rather flippantly of all supposed remedial measures. 

When we have any reason to suspect an hereditary tendency to 
tubercular meningitis, prophylactic measures may be used with hope of 
success. These consist in providing for pure air, ample clothing, nutri- 
tious food, and in the administration of cod-Hver oil, iron, iodine, and 

1 Op. et loc. cit. 



SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 259 

quinine. A climate not subject to sudden vicissitudes, and of such a 
character as regards warmth and dryness that the patient can spend a 
great portion of the day in the open air, is also a matter of prime im- 
portance. 



CHAPTER XI. 

SUPPURATIVE ENCEPHALITIS OB CEREBRITIS. 

Suppurative inflammation of the brain is a very rare affection un- 
complicated with meningitis. In this latter connection it has already 
been sufficiently considered. In the present chapter, therefore, I shall 
discuss it solely as an independent lesion, and mainly in reference to the 
subsequent formation of abscess. 

Symptoms. — The symptoms of suppurative inflammation of the brain 
vary according to the seat of the lesion, and are rarely of such a charac- 
ter as to enable us to say, with any great degree of certainty, that we 
have a case of uncomplicated encephalitis before us. Nevertheless, cer- 
tain phenomena have been recognized, and, after death, the evidences 
of inflammation of the brain have been discovered. But these symp- 
toms are, many of them, met with in other cerebral disorders, and there- 
fore cannot be regarded as pathognomonic. It is difficult, if not impos- 
sible, to arrange them in stages; and therefore, after the prodromata, I 
shall consider the phenomena of acute encephalitis in accordance with 
their relation to the several functions of the organism liable to be 
affected. 

The premonitory symptoms are similar to those of cerebral con- 
gestion, and doubtless depend upon a like pathological condition. Thus 
there are vertigo, pain in the head, noises in the ears, troubles of vision, 
numbness, and difficulties of speech. They never, however, last as long 
as they do in simple congestion. 

Sometimes the first-observed symptom of approaching encephalitis is 
an epileptiform convulsion. 

In the fully-established disease the phenomena are very decided, but 
at the same time have no necessary or constant relation with the pa- 
thology, as similar symptoms are met with in other very different affec- 
tions. 

Disorders of Sensibility. — At first, there is generally hyperesthesia; 
subsequently, anaesthesia. Headache is a common symptom, as it is in 
so many other cerebral diseases. There is no particular location of the 
pain — sometimes the frontal region, at others the occipital, and again 
the vertical or parietal regions, being its seat. It varies, likewise, as 
regards intensity and form, and may consist of a feeling of fullness or 



260 DISEASES OF THE BRAIN. 

constriction only. It is present from the very beginning of the disease, 
and usually continues through its whole course. 

Pains are felt in various parts of the body, are sharp and lancinating, 
and often attended with cramps. Cutaneous hyperesthesia is also oc- 
casionally met with. 

In the next place, there is anaesthesia, with all its accompaniments 
of formication, numbness, and other abnormal sensations of the kind, 
mainly affecting the face and upper extremities. As to the special 
senses, the sight is almost always deranged. There are bright flashes of 
light, iridescent appearances, and photophobia, all showing increased 
irritability of the retina. The pupils are contracted, the conjunctivae 
suffused, and the eyeballs are the seat of a dull, aching pain. Subse- 
quently, the pupils become dilated, and vision is lost. Ophthalmoscopic 
examination shows, in the early stages, papillary infiltration, with retinal 
congestion, and later, papillary atrophy and granular degeneration, the 
results of optic neuritis. There is also, generally, double vision, to 
which allusion will be more fully made directly. 

The hearing is at first very acute, and even slight noises are more or 
less painful. Noises in the ears, of various kinds, are present. As the 
disease advances, the hearing becomes much impaired, and is gradually 
lost, in one or both ears. 

The taste and smell are rarely affected. 

Disorders of Motility. — As with the sensibility, the motor organs of 
the body at first exhibit evidences of increased excitability. Thus, there 
are twitchings of the muscles, mainly of those of the face, and clonic or 
tonic spasms. Sometimes these last for several days. Subsultus is 
especially noticed in the flexor tendons of the wrist. 

General convulsions may take place, with or without loss of con- 
sciousness. Frequently the action is limited to one side of the body, or 
implicates one side of the face, or a single limb. Strabismus occurs, 
and double vision is produced, at this stage, from spasms of one of the 
ocular muscles. 

This period of muscular excitation corresponds very accurately with 
the stage of augmented sensibility. 

It is succeeded by a period of diminished motor power. Paralysis 
generally begins in a distant part of the body, and slowly involves one 
side. Thus, there may at first be a difficulty in raising the toes, or in 
grasping things with the fingers; then the knee becomes weak, the 
flexors of the thigh follow, and the whole limb drags. If the arm be the 
first member affected, the difficulty advances from the fingers to the 
elbow, and thence to the shoulder.' Sometimes the morbid action ex- 
tends equally on both sides of the body, and then the gait becomes 
weak and shuffling. The legs are spread wide apart, so as to increase 
the base, and keep the centre of gravity more easily within it. The 
knees are bent, the pelvis is flexed on the thighs, and the whole body is 



SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 261 

inclined forward. The face rarely escapes. It may be affected on one 
side only, in which case there is distortion, or there may be a gradual 
failure of muscular power on both sides. The muscles connected with 
the eyes almost always suffer. Ptosis is common, and external strabis- 
mus, causing double vision, accompauies it, both being produced by the 
implication of the third or motor oculi nerve. 

One side of the face sometimes becomes permanently contracted, 
and thus an appearance is produced somewhat resembling that which is 
caused by paralysis of the opposite side. It may be distinguished from 
this latter condition, however, by the fact that in it the eyelids are spas- 
modically closed, and the side of the face much more distorted than 
when there is paralysis of the opposite side. The tongue is always, in 
my experience, prominently affected. The first sign of diminished mo- 
tility is the frequency with which it is bitten, in conversation or masti- 
cation, and sometimes it is made quite sore, on one or both sides, or at 
the tip, from this cause. Then the patient discovers that long-continued 
speaking causes a sensation of fatigue, at the root of the tongue, and 
that a feeling as if this organ were too large for the mouth is expe- 
rienced. Then articulation becomes indistinct, the words are clipped or 
slurred over, so that at times it is difficult for others to understand what 
he says. 

Disorders of Intelligence. — The first indication of mental weakness 
is the susceptibility experienced to the influence of emotions. The 
patient will thus get uncontrollable fits of laughing or crying from very 
slight causes, and sometimes from no apparent cause. These paroxysms 
are frequently of mixed character, the patient passing from laughing to 
crying, and vice versa. 

The memory begins to fail at a very early period, especially as re- 
gards the names cf things. The enfeeblement is by no means, however, 
confined to words, but facts and circumstances likewise fail to be remem- 
bered. Gradually a condition of complete dementia ensues, and finally 
coma, with or without previous or alternating delirium. 

Disorders of the Functions of Organic Life. — There is always 
febrile excitement in encephalitis. At first the pulse is frequent, rising 
to 120, but as the disease advances it falls, till toward the close it goes 
below the normal standard. It is characterized, according to Barras, 1 
by a characteristic tremulousness (tremblottement), which he compares 
to the unequal vibrations of a cord moderately stretched. This pecu- 
liarity he attributes to irregular arterial dilatation. According to my 
experience, the symptom is by no means constantly met with, and it 
certainly is not pathognomonic, for the same peculiarity of pulse is 
found in several other disorders. In a case, however, now under my 
care, in which there is reason to suspect encephalitis and abscess, the 
phenomenon is present in a marked degree, not only in the radial 
1 "Bulletin de la societe medicale d' emulation," Juki et Octobre, 1823. 



262 DISEASES OF THE BRAIN. 

artery, but in the temporal and the angular, as it passes between the 
nose and the inner angle of the orbit. 

The respiration in the first stages is not materially deranged, but 
later it becomes irregular and stertorous, and finally asphyxia may take 
place. 

The temperature of the body is elevated till the fever abates, and 
paralysis makes its appearance. The thermometer rarely, however, 
goes above 103° Fahr., and is generally a degree below this point. 

The digestive organs usually show more or less evidence of derange- 
ment. Constipation is always a prominent feature, and the appetite 
is capricious. At times the patient refuses to eat, at others he will 
cram his stomach with all kinds of edibles. Deglutition is often troub- 
lesome, and occasionally dangerous, from paralysis of the pharyngeal 
muscles. Cases are on record in which death has occurred by the food 
becoming impacted in the throat, and several cases have come under my 
own notice, in which, from a like cause, a fatal result was barely pre- 
vented by the use of very energetic measures. 

Moreover, the secretions of the mouth are almost always altered 
either in quantity or quality, or both, and the sensibility of the tongue 
and f aucial mucous membrane is often impaired. Hence, the patient is 
not aware that he has filled his mouth, and goes on cramming it with 
food, which makes an alimentary mass larger than can pass through 
the oesophagus. This, of course, even without the pharyngeal paralysis, 
interferes with the act of swallowing. The fasces are sometimes passed 
involuntarily, but this is almost entirely a feature of the last stage. 
Nausea and vomiting are present more or less from the very first. 

There may be either retention of urine from paralysis of the bladder, 
or incontinence from paralysis of the sphincter. Or both conditions 
may coexist, giving rise to a constant dribbling. 

These symptoms may be arranged in five classes, designated by the 
most prominent feature of each: the paralytic, the comatose, the epi- 
leptiform, the apoplectiform, and the maniacal. 

Complications may and often do arise. Thus there may be menin- 
gitis, temporary congestions, extravasation of blood, effusion of serum, 
or some intercurrent visceral affection. 

The tendency of acute encephalitis is to suppuration and the conse- 
quent formation of abscess, and many of the symptoms enumerated are 
due to the supervention of this condition. Death ensues gradually 
from exhaustion or asphyxia, or may take place suddenly from the 
bursting of the abscess into the ventricles, or upon the surface of the 
brain. 

Causes. — No age is exempt from the disease, although it is more 
common in old persons than in adults of middle age or young persons. 

It is probably more frequent in males than females solely from the 
fact that they are more subject to the exciting causes of the disease. 



SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 263 

Among these are the inordinate use of alcoholic liquors, venereal ex- 
cesses, extreme intellectual exertion, great emotional disturbance, and 
exposure to extreme heat. 

It may also be induced by disease of the internal ear, by erysipelas 
affecting the head, or by severe attacks of scarlet fever, small-pox, or 
other eruptive disease. 

The most common cause, however, is injury of the brain. 

Diagnosis. — The diagnosis of suppurative encephalitis is, in the first 
stages, difficult if not impossible; the symptoms being common, as I 
have already said, to several other disorders. From cerebral haemor- 
rhage the distinction can be made without difficulty, for, although en- 
cephalitis may be developed with rapidity and by an apoplectic seizure, 
the tendency is for the subsequent phenomena to become progressively 
more marked, while in haemorrhage there is a gradual amelioration. 
The pulse in haemorrhage is from the first slow and regular, unless the 
medulla oblongata be the seat, while in encephalitis it is rapid and ir- 
regular. 

Meningitis is always associated with superficial encephalitis, and 
hence the symptoms bear a certain amount of resemblance to those of 
the affection under consideration. But the latter is, in general, charac- 
terized by the facts that the paralysis is more defined, both in intensity 
and location; that the delirium is less acute; that the cephalalgia is not 
so intense, nor the delirium so prominent or constant a phenomenon. 

In epilepsy the paroxysm is the main phenomenon of the disease. 
When this ceases, the patient in general recovers his ordinary mental 
faculties, but the epileptiform seizures of suppurative encephalitis are 
never followed by complete intellectual restoration. 

The disease with which it is most likely to be confounded is that 
which, from its obvious characteristics, is denominated general paralysis. 
I know of no diagnostic marks between the two conditions, except that 
general paralysis is usually of longer duration, and is ordinarily charac- 
terized by a peculiar form of mental aberration — the d'elire des gran- 
deurs of the French. 

The symptoms due to tumors are often almost identical in character 
with those attendant on abscess. The history of the case is our only 
safe guide. The fact that the brain has received an injury of some kind 
will indicate suppurative encephalitis as the probable difficulty. A lady 
is, at the moment of writing this, under my charge, who has been suc- 
cessively treated by several of the most skillful diagnosticians of this 
city, at times for abscess, and again for tumor, and I venture to say that 
no one, without the aid of a post-mortem examination, can say which 
lesion exists. 

Prognosis. — Suppurative encephalitis is invariably fatal, if the dis- 
ease does not terminate in resolution. As Jaccoud, however, remarks, 
cases of alleged cure before the stage of suppuration is reached must 



264 DISEASES OF THE BRAIN. 

always have an element of uncertainty about them, and do not there- 
fore permit us to mitigate the unfavorable character of the prognosis. 
Drs. Gull and Sutton, 1 while stating that there is nothing in the morbid 
anatomy of cerebral abscess which makes it necessarily an incurable 
affection, admit that practically it is irremediable. In this opinion I 
unhesitatingly concur. 

Morbid Anatomy and Pathology. — Suppurative encephalitis is a local 
disease restricted in its action, and hence affecting a limited and well- 
defined region of the cerebral tissue. This may vary from the size of a 
walnut to that of the closed fist, and is ordinarily irregularly spherical 
in shape. Although never of a diffused character, there may be, at the 
same time, several centres of inflammation. The part most frequently 
affected is the gray matter of the cerebrum — the morbid process in- 
volving the white substance in its progress. Next, the cerebellum ap- 
pears to be a favorite seat. The corpora striata, and the optic thalami, 
are also frequently involved. 

It sometimes happens that the pus which results from the inflamma- 
tory action is not collected in a cavity, but is infiltrated into the sub- 
jacent tissue. In such cases there is no well-defined abscess, but a 
pulpy mass is found on examination after death, consisting of the ele- 
ments of the brain-substance in a more or less disorganized condition, 
with those of the blood intermingled with pus — the whole of a greenish- 
yellow color. 

Again, there may be a collection of pus, but at the same time the 
walls are imperfectly formed, and there is infiltration to some extent. 
Lastly, the puriform deposit is entirely limited by a membrane consist- 
ing of connective tissue, and forming a cyst. The cerebral substance in 
contact with the walls of an abscess gradually breaks down, and hence 
the cavity undergoes constant enlargement in all directions, but espe- 
cially in the lines of least resistance. If the abscess is near the surface 
of the hemisphere, the tendency is to enlarge toward the external 
periphery ; if it is situated in the central part, in the corpora striata or 
optic thalami, the absorption of the peripheral tissue takes place in the 
direction of the ventricles. In the first instance, when the rupture en- 
sues, the pus will be extravasated into the cavity of the arachnoid; in 
the second, it will be poured out into the ventricular cavities. In either 
case, coma and death will result if the amount of pus be sufficiently 
large. It has happened that the pus has escaped from the cranium by 
the nose or ear. A lady now under my charge experienced this result 
several weeks since; a large quantity of purulent matter making its 
exit through the posterior nares. She is still alive, in full possession of 
her reasoning faculties, and her articulation perfect, but with the loss 
of sight in both eyes, paralysis of the right side of the face, the left 
arm, and leg, and suffering the most intense and constant pain in her 
1 " Abscess of the Brain," Keynolds's " System of Medicine," vol. ii., p. 544. 



SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 265 

head. The seat of the lesion is probably partly in the right half of the 
pons Varolii. The suppurative action is doubtless still going on, and I 
regard her death as inevitable. 1 

The substance of the brain in contiguity with the abscess, as already 
stated, undergoes disintegration. This is in the nature of softening. 

CHR02TCC CEKEBRAL ABSCESS. 

Suppurative inflammation of the brain, terminating in the formation 
of abscess, may be of a chronic character, the course of the disease ex- 
tending over several months. This is especially apt to result from dis- 
ease of the internal ear. 

Cases have been reported by Abercrombie, 2 Lallemand, 3 Toynbee,* 
Ribiere, 6 and others, and three have come under my own observation. 

Chronic abscess may also result from injuries of the brain or skull, 
and from suppuration set up around a clot due to extravasation of 
blood. 

As in the acute form of the disease, there are no very characteristic 
symptoms indicating the formation of abscess. Indeed, in some cases 
there are no symptoms at all referable to the brain for the whole period 
of the course of the disease, till a short time before death. A great 
part of a lobe may be destroyed, and even both anterior lobes almost 
entirely obliterated, and the patient continue to manifest his ordinary 
degree of intelligence. 

Ribiere 8 has collected a number of interesting cases, several of 
which almost overturn some of our most definite ideas of cerebral physi- 
ology and pathology. Thus, he cites (Observation II.) the case of a 
man who entered the Hdpital de la Pitie, January 27, 1866. The pa- 
tient was depressed, answered questions with difficulty, and complained 
of a violent pain in the head. The symptoms were supposed to indi- 
cate the 'existence of typhoid fever. Two days subsequently a purulent 
discharge was noticed from the right ear, and, the pain in the head per- 
sisting, the diagnosis was changed to suppurative otitis, with probable 
caries of the petrous portion of the temporal bone. Leeches were ap- 
plied behind the ears and 'purgatives administered, after which the 

1 This patient died shortly after the foregoing lines were written. She gradually passed 
into a state of profound coma, in which state death occurred. The pus continued to be 
discharged in small quantity up to the last, and microscopecal examination disclosed the 
existence of ganglion-cells containing granular matter, oil-globules, and other remains of 
broken-down nervous tissue. No post-mortem examination could be obtained. 

2 " On Chronic Inflammation of the Brain and its Membranes," Edinburgh Medical 
and Surgical Journal, vol. xvi., 1818, p. 265, et seq. 

3 Op. cit., p. 80, et seq. 

4 " The Diseases of the Ear," etc., Philadelphia, 1860. 

5 " Des abces de l'encephale consecutifs a la carie du rocher." These de Paris, 
1866. 6 Op. cit. 



266 DISEASES OF THE BRAIN. 

patient felt so far well that he determined to leave the hospital. He 
went to work again, and, on the 12th of February, attended a ball. 
The following morning, pus, mixed with blood, was discharged from 
the right ear, and, the tendency to stupor reappearing, he again 
presented himself at the hospital. It was then ascertained that th6 
flow from the ear had begun several years previously, but had ceased 
for the two years immediately preceding his first entrance into the 
hospital. 

On the 14th he was in a state of not very intense stupor, since he 
was able to complain of the pain in the head; his pulse was 60, full and 
hard, and pus was passing from the right auditory canal. By the 16th 
of February the stupor had increased. There was no paralysis, devi- 
ation of the face, nor alterations of sensibility. The patient under- 
stood questions put to him, but answered slowly and imperfectly. The 
eyelids were closed, light appeared to be unpleasant, and the purulent 
flow still continued. He died at nine o'clock that night, without con- 
vulsions. 

The post-mortem examination of the head revealed the following 
condition: 

The external auditory canal was filled with desiccated purulent mat- 
ter; there was neither abscess nor abnormal redness about the ear. 

The superior longitudinal sinus was gorged with blood, the veins 
were black and dilated; the brain appeared congested, but a yellow 
tint of the right cerebral lobe was noticed. At the inferior face of this 
lobe, where a rupture had occurred in handling the brain, a quantity of 
pus estimated at one hundred grammes (about three ounces) flowed 
out. This was of a greenish color, and of offensive odor. The cavity 
left was about the size of a hen's egg, and was bounded by red, indu- 
rated, and thick walls. The pus, which during life had flowed from the 
auditory canal, had not come from the abscess, but from the carious 
petrous portion of the temporal bone. 

Around the abscess the substance of the brain was yellow and soft- 
ened. Three-fourths of the middle and posterior lobes were infiltrated 
with pus and softened in texture. The capillaries were not visible to 
the naked eye; the convolutions of the island of Reil were not recog- 
nizable, and the neighboring convolutions were not now distinct. The 
corpus striatum of the right side was healthy in its anterior fourth. In 
the rest of its extent it was softened. The optic thalamus was also 
softened, as were likewise the roots of the optic nerve. We see that, 
in this case, as Ribiere remarks, a considerable abscess had destroyed, in 
great part, the corpus striatum and optic thalamus, and that, neverthe- 
less, the patient had been able to work till within a few days of his 
death, and was so slightly paralyzed as to be able to attend a public 
balk Aside from a certain hebetude, the intellectual faculties were not 
deranged. 



SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 267 

Another patient observed by Ribiere presented an entire absence 
of cerebral troubles, no paralysis, no contractions, no convulsions; the 
sensibility was intact, and the intelligence was active. Nevertheless, 
there was a degree of stupidity expressed in the countenance, and the 
expression was dull. Still there is almost always some pain in the head, 
which may be irregular as regards its location and character, or may 
oe confined to one particular spot. 

In one of the cases under my observation, there was very acute pain, 
almost constant nausea or vomiting, a strong tendency to coma, and 
hemiplegia of the left side, coexisting with purulent discharge from the 
right ear. The patient, who had a short time previous suffered an attack 
of scarlet fever to which the ear-trouble was due, died suddenly, coma- 
tose, but without convulsion. Examination after death showed the 
existence of caries of the petrous portion of the temporal bone, and an 
abscess containing about two ounces of pus in the middle lobe of the 
right hemisphere. The right corpus striatum was softened in about 
half of its extent. 

In the other case there had been profuse discharge from the right 
ear for several years, unattended by any cerebral symptoms except 
occasional pain and headache, which were supposed by the f amity to be 
due to gastric derangement, and for which no medical advice was ever 
asked. One morning the patient, a young lady, twenty years of age, 
was suddenly roused from bed by an alarm of fire. In her hurry to 
dress herself, and in the confusion of the moment, she struck her head 
against the edge of an open door. She immediately felt a severe pain 
in the head and cried out, but almost instantly sank down to the floor 
in a stupor, from which she never emerged, death ensuing within five 
hours. On removing the calvarium a large extravasation of pus was 
discovered under the arachnoid, covering the right hemisphere, and it 
was ascertained that an abscess, the cavity of which was as large as a 
small orange, had occupied the middle lobe, and had burst through the 
convex superior surface by rupturing the cerebral substance. The 
petrous portion of the temporal bone of that side was carious, and com- 
municated by several very small openings with the abscess. 

When speaking of cerebral haemorrhage, I have referred to another 
case in which there was abscess of the cerebellum, produced by injury 
of the skull. In this instance there were notable symptoms, vertigo, 
convulsions, nausea, vomiting, and violent pain in the back of the head. 
At first there was no paralysis, but the patient subsequently became 
paraplegic, and died in convulsions. Examination after death disclosed 
an abscess, the cavity of which comprehended nearly the whole of the 
left lobe of the cerebellum. 

Prof. Roosa, 1 while expressing the opinion that a suppurative pro- 

1 " A Practical Treatise on Diseases of the Ear, including the Anatomy of the Organ," 
New York, William Wood & Co., 1873, p. 446. 



208 DISEASES OF THE BRAIN. 

cess of the ear is probably necessary for the production of an abscess 
of the brain, reports a case which leads him to suspect that there may 
be such a thing as a chronic cerebral abscess leading to disturbing aural 
symptoms, such as tinnitus aurium, and pain in one side of the head, 
without any primary aural affection. He treated a gentleman, of about 
twenty-nine years of age, for some months for such symptoms as have 
been indicated, and when he died a cerebral abscess was found. He 
could hear the watch for but three inches from the left ear, which was 
the affected one, and the drum membrane was sunken. Prof. Roosa 
supposed the case to be one of chronic proliferous inflammation of the 
middle ear. The patienb got no relief; he became very despondent on 
account of his tinnitus aurium, and gave up his business and died at Sag 
Harbor, Long Island, of malignant pustule, about two years and a half 
after Prof. Roosa first saw him, and three years and a half after his first 
aural symptoms. 

Dr. George A. Sterling made a post-mortem examination, and 
found great injection of the pia mater over the petrous portion of the 
temporal bone, and an abscess about the size of a ten-cent-piece in the 
brain-substance. It was bounded by inflammatory adhesions, and con- 
tained about ten drops of pus. The abscess was situated on the left 
side, in the superior lobe, one inch from the median line, and two 
inches from the coronal suture. In this case there had never been a 
suppurative inflammation of the ear. 

The fact that abscess of the brain may occur without being preceded 
or accompanied by suppuration of the ear is beyond doubt. 

Although recovery from chronic abscess of the brain never takes 
place, yet life is often prolonged for several years, even when there may 
be marked symptoms of cerebral disorder. And when death occurs it is 
generally suddenly, with or without obvious exciting cause. 

Treatment. — The treatment of acute suppurative encephalitis is alto- 
gether palliative. Symptoms, such as pain, vertigo, and vomiting, may 
be controlled to a certain extent. I have derived considerable benefit 
from the extract of Indian hemp, given in conjunction with the bromide 
of potassium. The doses of Squires's extract may range from half a 
grain to two grains three times a day, with from thirty to forty grains 
of the bromide, either of potassium or sodium. The pain and irrita- 
bility of the nervous system are greatly lessened by these remedies, and 
thus the patient's condition rendered more tolerable. 

When there is reason to suspect a syphilitic origin, mercury and 
iodide of potassium may be administered theoretically with some pros- 
pect of success, but practically with very little benefit. The medicines 
should be given in frequently -repeated doses — calomel being the prefer- 
able mercurial — so as to bring the system, as soon as possible, under 
their influence. 

Bloodletting, local and general, blisters, tartar-emetic, and other 



SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 269 

measures calculated to depress the powers of the system, are worse than 
useless. 

In suppurative disease of the internal ear, probably due to caries of 
the petrous portion of the temporal bone, preventive measures against 
chronic abscess may do something. Leeches applied to the mastoid pro- 
cess, and blisters behind the ear, are indicated, and mercury with iodide 
of potassium will afford a chance of a beneficial result. The solution of 
the bichloride of mercury with iodide of potassium in water constitutes 
an eligible preparation. The flow of pus should be facilitated, and the 
propriety of trephining the mastoid cells may be a question for consid- 
eration. The management of injuries, with a view to preventing abscess, 
is to be conducted upon very obvious surgical principles. 



Note. — Under the name of Cerebria Dr. Charles Elam * has de- 
scribed an affection of the brain which he defines as " a spontaneous, 
acute general inflammation of the substance of the brain uncompli- 
cated with meningitis." Dr. Elam has, in my opinion, adduced very 
strong evidence of the existence of such a disease, but I am not quite 
sure that the symptoms and morbid anatomy are sufficiently character- 
istic to warrant at present its introduction into our nosology as a patho- 
logical entity. He says : 

" It is a disease which may, perhaps, occur at any period of life, 
although I have never seen it before eight nor after thirty-six years of 
age. It is certainly much more frequent between ten and thirty than 
at any other ages. It is uniform in its commencement as its termina- 
tion. It begins with vomiting, and it ends with death. The inter- 
mediate phenomena are not very striking, and the duration is from 
thirty-six hours to twelve days. It differs in the most marked manner 
from the forms of encephalitis hitherto described, in its causation, its 
mode of invasion, its progress, and its morbid anatomy." 

I cite the following case, which will give a good idea of the affec- 
tion in question : 

" H. F., a boy, aged ten, previously in good health, vomited once 
on the morning of June 10th. In the evening I saw him, and was in- 
formed that, he was then much better. He had complained slightly of 
headache at the moment of vomiting, but there was little or no remains 
of the pain afterward. He was not in bed, and seemed very much in his 
usual state, except some little languor. The pulse was about seventy, 
regular and moderate in tone. The tongue was slightly furred, and 
the bowels not quite so regular as in ordinary. He denied positively 
and repeatedly having any pain in the head, or feeling ill in any way. 
I could detect no such alteration in the pupils, nor such modification 
in any visible or perceptible organ or function, as to lead me to suspect 

1 "On Cerebria and other Diseases of the Brain," London, 1872, p. 32. 



2T0 DISEASES OF THE BRAIN. 

serious disease. My prescriptions were little more than formal direc- 
tions as to diet and general management. 

"For reasons unnecessary to mention, I called at the house the 
next day, about 11 A. m. The mother said, in answer to my inquiries, 
that her son must be better, he had slept so well, and was, in fact, 
asleep still. This at once excited my suspicions, and, going up-stairs, 
I found the boy pulseless, rather cold, and unable to be roused to any 
degree of consciousness. From this condition he never rallied, and he 
died the same afternoon, about thirty-two hours after the vomiting. 

" Post-mortem Examination, Thirty-five Hours after Death. — No 
trace of disease in the stomach, or any of the abdominal or thoracic 
organs. Head. — The sinuses a little more full than usual, but the 
membrane showing no signs whatever of disease. There was no effu- 
sion, except to a very trifling amount in the lateral ventricles. The 
brain-substance alone showed marks of pathological change, being very 
closely dotted with red spots ; the gray matter was darker than usual, 
and the white matter slightly rosy. The texture of the brain seemed 
to be almost normal, neither being softer nor harder than the average. 
There was no microscopical examination made of any part of the brain; 
but no doubt remained on the mind that this was a case of pure, un- 
complicated, idiopathic inflammation of the brain-substance." 

In another case " the whole mass of the brain was so altered in 
texture by inflammatory action that it could not support its own 
weight, nor hold together. No sooner was it removed from the head, 
and placed on a dish, than it gave way, falling prone together and 
flattening like an imperfectly-made form of jelly. The commissures 
were all ruptured by the weight of the hemispheres. The white mat- 
ter of the brain was throughout soft, and pinkish in color. On cutting 
it, it smeared the knife with a streaked stain. Microscopically ex- 
amined there was no pus, but an abundance of exudation corpuscles." 

My reasons for somewhat doubting that these were cases of " a 
special cerebritis, uncomplicated, general, and idiopathic," are : That 
the structural changes may have begun long before they were evi- 
denced by any notable symptoms, and hence may have existed for 
some time before coming under Dr. Elam's notice, and that the con- 
dition discovered after death may have jesulted from occlusion of some 
one or more of the cerebral blood-vessels. Nevertheless I am inclined 
to think that Dr. Elam has made out his case ; at any rate, he has made 
a very interesting and important contribution to cerebral pathology. 



DIFFUSED CEREBRAL SCLEROSIS. 271 



CHAPTER XII. 

DIFFUSED CEREBRAL SCLEROSIS. 

By diffused cerebral sclerosis is to be understood a morbid condition 
of some part of the brain characterized by induration and atrophy of 
the tissue, and not distinctly circumscribed except by the anatomical 
limits of the region affected. 

It is not a disease which can be recognized with any great degree of 
certainty or even of probability during life. It is, however, a well- 
marked pathological condition, giving rise to very prominent symptoms. 
Of late years the affection has not been much noticed, except incident- 
ally, by a few writers of special treatises — though, under the name of 
" induration of the brain," it received considerable attention many 
years ago. 

The symptoms by which it is characterized are by no means peculiar 
to it, though, when taken collectively, they give us some reason to diag- 
nosticate sclerosis as their cause. A number of cases have come under 
my observation in which the lesion was probably diffused cerebral sclero- 
sis ; but I have never had the opportunity of verifying my diagnosis by 
post-mortem examination. The remarks, therefore, which I shall make 
on the morbid anatomy will mainly be based upon the studies and obser 
vations of other writers. 

Symptoms. — The symptoms of diffused cerebral sclerosis, like so many 
other brain-affections, are connected with the mind, with sensibility, and 
with the power of motion. It generally makes its appearance during 
infancy, and produces an arrest of development in the part of the brain 
affected, and consequently in certain parts of the body. The initial 
phenomena are those of congestion and inflammation, during the course 
of which epileptic convulsions frequently ensue. These may be few in 
number, and may cease in a few days, or they may be very frequently re- 
peated and last for several years, or during the whole life of the patient. 
The mind remains undeveloped, speech, if already acquired, often becomes 
imperfect, and, if not yet present, may never be commenced. The limbs, 
usually only on one side of the body, become paralyzed, and do not grow 
with the same rapidity as those on the sound side. Contractions are 
very apt to take place, from the fact, probably, that the normal degree 
of antagonism between the muscles is destroyed, and that those not ' so 
much paralyzed as others draw the limbs in the direction of their action. 
It is quite common, therefore, in the affection under consideration, to 
find the fingers drawn into the palm of the hand, the wrist flexed on the 
forearm, the forearm on the arm, and the arm drawn backward by the 



272 DISEASES OF THE BRAIN. 

action mainly of the latissimus dorsi. In the lower limbs, club-feet are 
produced in a similar manner. 

It is not uncommon, too, to find one or more senses weak or alto- 
gether lost, and the general sensibility of the body diminished on one 
side. 

The urine and faeces are often passed involuntarily, or else the patient, 
from never having acquired a sense of propriety or cleanliness, passes 
them whenever he chooses, at any time or place. 

With this general idea of the symptoms, I proceed to refer some- 
what at length to its histcry, in the course of which I shall quote several 
cases in illustration of its progress. 

The first to direct specific attention to the disease under consideration 
was M. Pinel, 1 the younger, who, in a memoir read before the French 
Academy of Sciences, May 27, 1822, brought forward several cases in 
illustration of what he denominated " induration of the brain." I quote 
the first case in full as a typical example of the affection: 

Beler, aged eighteen years, an idiot from birth, was admitted into 
the Salpetriere Hospital, June 1, 1821. The patient was paralyzed in the 
left arm and leg. She could not use this arm, for the hand was strongly 
flexed on the forearm, and could not be extended. She walked with 
great difficulty, dragging the left leg. Her intellectual faculties were 
very much restricted ; she comprehended only the questions which were 
addressed tc her relative to her health, her intelligence not extending 
beyond that point, She had also great difficulty in articulating the 
words yes and no, which were the only words she could speak. She had 
no particular habit, Was always calm and tranquil, and had to be antici- 
pated in all her wants. She was subject to occasional attacks of epi- 
lepsy ; but, when the paroxysms came on, she had fits almost without 
intermission for thirty or forty hours. They returned about every 
twenty -five days. On the 4th of December, 1821, the patient was taken 
with a series of epileptic fits, almost continual in character, which lasted 
during four days, the paroxysms succeeding each other with inconceiv- 
able rapidity. During these continuous convulsions the right limbs 
were affected with violent movements. The left ljmbs, which had been 
paralyzed for a long time, were also strongly agitated, and the general 
sensibility was abolished. The face was red, the eyes were twisted, the 
dejections were passed involuntarily, the pulse was frequ.ent and irreg- 
ular, and the respiration unequal and jerking. The patient died on the 
fourth day, without there having been any remission in the symptoms. 

Post-mortem Examination. — " General marasmus ; remarkable ema- 
ciation of the paralyzed limbs. The cranium was thick, eburnated, and 
rery hard to break. The meninges were pale and healthy. The right 
lobe [hemisphere] of the brain was very much smaller than the left, it 

1 "Recherches d'anatomie pathologique sur l'endurcissement du systeme nerveux," 
Journal de Physiohgie de Magendie, tome ii., 1822, p. 191, et seq. 



DIFFUSED CEREBRAL SCLEROSIS. 273 

was atrophied ; the convolutions were almost obliterated and very small, 
especially in the frontal and occipital regions. They were large and 
deep in the inferior part. The cortical substance was thicker than it 
generally is ; the lateral ventricle was very small and dry. The sub- 
stance of the brain, throughout the whole extent of this right lobe 
[hemisphere], and notably above the ventricle, was of remarkable hard- 
ness, and it was torn with difficulty by the fingers, the tissue separating 
in longitudinal bands which converged toward the corpus striatum. 

"The left lobe [hemisphere] of the brain, much more developed 
than the right, was of the softness and consistence of the healthy brain- 
tissue, and this condition made the alteration in the right lobe [hemi- 
sphere] more obvious." 

The rest of the description refers to other organs. 

In regard to this case, M. Pinel remarks that to the pathological 
condition, the loss of the power of motion in the whole of one side, 
the almost complete annihilation of the intellectual faculties, and prob- 
ably the epileptic fits, are to be ascribed. The condition — which is fre- 
quent with idiots, but of which it is often difficult to estimate all the va- 
rious symptoms — is ordinarily revealed less by the paralysis of the limbs 
than by the distortions which it determines in the feet and the hands. 
Three other cases are adduced, in one of which the cerebellum was also 
in part indurated. M. Pinel, as the result of his observations of the 
morbid anatomy, states that the nervous tissue resembles a compact in- 
organic mass ; its consistence and density are those of hard-boiled white- 
of-egg ; the cerebral substance is atrophied ; it appears entirely de- 
prived of blood-vessels — the eye perceiving no trace of capillaries. The 
induration appears to affect more particularly the medullary sub- 
stance than the gray substance ; it was never observed in this last-named 
tissue. 

Griesinger, 1 under the name of "diffused hypertrophy of the con- 
nective tissue of the brain," describes the affection now under consid- 
eration, and refers to an interesting case reported by Isambert, 2 in 
which a microscopical examination of the altered tissue was made. It 
occurred in an idiotic child, two years of age. The ventricular walls, 
the great ganglia, the pons and peduncles, were solid and hard ; their 
tissue was elastic, like caoutchouc ; the nerve-tubes in the white sub- 
stance were almost completely destroyed and an amorphous granular 
substance occupied their place ; there also existed newly -formed fibrous 
connective tissue. In regard to such cases, Griesinger remarks that, 
when we are told that a hitherto healthy and well-developed child, about 
the period of dentition, or during the second or third year, suddenly 
became feverish, was attacked with convulsions and delirium, fell into 

1 "Die Pathologie und Therapie der psychischen Krankheiten," Zweite Auflage, 1861, 
p. 301. Also "New Sydenham Society Translation," p. 359. 

* " Comptes rendus et memoire de la Societe de Biologie," tome ii., 1856, p. 9. 
19 



274 DISEASES OF THE BRAIN 

a slightly soporific state, and soon afterward apparently recovered, but 
with the intellectual and physical development checked, the condition 
may be due to one of two morbid processes : either there are slight con- 
gestion and inflammation of the membranes, or there is encephalitis, 
which, after passing out of the acute stage, suspends further develop- 
ment in the affected parts. The mind, therefore, ceases to expand ; 
walking, if begun, is arrested ; speech remains as it is, or is altogether 
lost ; one side of the body does not grow so fast as the other ; and con- 
vulsions, paralysis, and contractions, are present. 

A case in point, referred to by Griesinger, I quote from Calmeil : ' 

"M. Alfred, born at Havre, single, aged twenty -two years, came to 
the Bicetre, where he resided twenty-two months : he had been an in- 
valid since infancy. 

" Until about three years of age, he had exhibited no peculiarity as 
regarded intelligence — resembling other children of his years. 

" At this period, however, he was attacked with measles, which was 
considered mild in form, and from which he had nearly recovered, when 
he was seized with a succession of severe eclamptic paroxysms. During 
twelve hours, it was impossible to rouse him from the coma, and gen- 
eral convulsions were present almost without interruption. 

" The day after, it was perceived that he was deaf, blind, and in- 
capable of articulating the least sound ; the convulsions had ceased. 

" At the end of fifteen days he recovered his hearing ; after a year 
he could say a few words ; but the retinae continued insensible to im- 
pressions of light. 

" It was now perceived that he walked with a certain degree of diffi- 
culty, and that he could hardly use the right hand. At times, also, he 
lost consciousness, but without falling, and it was subsequently recog- 
nized that these attacks were epileptic. 

" Until the age of thirteen, the intelligence of M. Alfred underwent 
scarcely any development, and he remained imbecile notwithstanding all 
the efforts made for his improvement. He nevertheless acquired a knowl- 
edge of a certain number of words, and he could make himself under- 
stood whenever he had a want to gratify. 

" At the age of nineteen he presented the symptoms of an almost 
complete state of idiocy. He comprehended some things, and could 
imperfectly articulate a few words. He was not evilly disposed, but he 
was incapable of attending to his person, and even of eating without 
assistance. 

"He could take a few steps by supporting himself against the wall, 
on articles of furniture, or a cane, but he dragged his feet on the ground, 
and his right leg appeared to be weaker than the left. The right arm 
was contracted and almost immovable. Tactile sensibility was not af- 
fected, anywhere. He did not appear to perceive objects placed imme- 

1 "Traite des maladies inflammatoires du cerveau," Paris, 1859, tome ii., p. 411. 



DIFFUSED CEREBRAL SCLEROSIS. 275 

diately before his eyes, and the pupils were dilated and insensible to the 
sudden accession of light. As regarded the bladder and rectum, he 
evacuated them without seeming to exercise the least restraint of clean- 
liness or propriety. 

" The epileptic paroxysms occurred with long intervals between 
them, and presented no characteristics worthy of special mention. The 
complexion was pale, and the body emaciated and notably weak. 

"During the month of January, 1827, there was frequent cough, 
combined with abundant expectoration, diarrhoea, and other symptoms 
of phthisis." He died in February of the same year. 

Autopsy. — The whole of the right side of the body was much less 
developed than the left side. The right arm and leg were especially 
emaciated and thin. " The face was free from distortion, and the cra- 
nium, without being deformed, was small and very narrow. The greater 
part of the cranium was abnormally thick, and contained an excessive 
amount of calcareous matter. 

" The dura mater was without change, and did not adhere to the 
osseous surfaces. 

"A very considerable quantity of serum was infiltrated into the 
meshes of the pia mater — principally toward the middle and convex 
surface of the two cerebral hemispheres. The pia mater was thickened, 
but was not adherent to the convolutions. 

" The left cerebral hemisphere was notably smaller than the right : 
the posterior lobe being particularly remarkable for its diminution. 
The convolutions were flattened, and were as thin as the blade of a 
knife, were resistant to the touch, and were of a clear yellow color. 
The middle and anterior lobes were neither of them of ordinary size. 

" The posterior lobe of the right hemisphere was less developed than 
in a healthy brain, but the number of atrophied convolutions was small. 

" On cutting into the left posterior lobe with a bistoury, its tissue 
was found to be white, compact, homogeneous, and very resistant. It 
might be said that the cerebral substance had become doughy, and that 
an element, foreign to its nature, gave it an excessive degree of hardness. 

"On the right, the atrophied convolutions of the posterior lobes 
were difficult to cut ; their structure was compact, but the induration of 
the nervous tissue did not extend deeply into the thickness of the lobe. 

" In all other parts of the brain the white and the gray substance, as 
well on the left as on the right side, were apparently, in all respects, in a 
nealthy condition. 

" The corpora striata and the optic thalami were free from change, 
either as regarded their volume or their structure. 

" The pons Varolii, the tubercula quadrigemina, and the peduncles 
of the cerebrum, and cerebellum, were in a normal state. 

" The spinal cord relatively, and perhaps even absolutely, appeared 
to be larger than was natural. 



276 DISEASES OF THE BRAIN. 

" The optic nerves were atrophied, of a glossy white color, and very 
hard." 

Other cases, similar in general features, are adduced by Calmeil. 

In the very interesting monograph of Cotard, 1 to which reference 
has already been made, the relation of sclerosis to atrophy of the brain 
is clearly pointed out. As indicating a certain set of symptoms, in 
existence with a definite pathological state, I quote the following case, 
No. XXIX. of his series. 

" C, aged fifty-eight years, an inmate of the Salpetriere since 1828, 
entered the infirmary on the 25th of April, 1865, under the charge of 
M. Charcot. 

" She gave the following information, which she said she had from 
her mother, and from other persons who had brought her up : At the 
age of eighteen months she had three attacks of convulsions, which left 
her paralyzed on her right side. She had never had convulsions since. 
She had already begun to walk when the seizures took place, but she 
did not walk again till she was three years old. 

" According to the information given by the superintendent of her 
ward, who had known her since her entrance into the hospital, her intelli- 
gence had always been weak; she was incapable of attending to herself; 
she could read tolerably well, and could sign her name ; she had always 
spoken without difficulty. 

" She had been employed with coarse sewing, and had invariably 
been docile and attached to those who took care of her. 

" Her health had always been good, though she had, when about the 
age of twenty-five or thirty, several attacks of hysteria. Menstruation 
had been regular, and had ceased when she was forty-five. 

" For about a year the patient had been the subject of frequent at- 
tacks of vomiting, or of epigastric pain. At the time of her admission 
to the infirmary, she was very much emaciated and very cachectic. 

" Her intelligence did not appear to have been recently enfeebled ; 
she could read, sign her name, and speak without difficulty. 

" Her senses seemed to be intact ; sight was good in both eyes, and 
the pupils were equal. There was no facial paralysis, and the tongue 
was protruded straight. 

" The right arm was emaciated, atrophied, and contracted ; the fore- 
arm was pronated and semi-flexed on the arm ; the hand was flexed on 
the forearm, and inclined toward the ulnar side ; the fingers were flexed 
in the palm of the hand, particularly the ring and little fingers ; the 
index-finger was semi-flexed, and the thumb was extended. 

" It was possible, without very great force, to bring the several parts 

of the limb almost into a state of extension, but, as soon as it was left 

to itself, it resumed its habitual position. The patient could execute a 

few movements with the shoulder and the elbow, but the wrist was ab- 

1 " Etude sur l'atrophie partielle du cerveau," Paris, 1868, p. 49. 



DIFFUSED CEREBRAL SCLEROSIS. 277 

solutely paralyzed, and the fingers could only be moved to a very lim- 
ited extent. 

" The right leg was less atrophied, and there was no other deformity 
than a talipes equinus. The patient walked with a cane. 

" The sensibility of the right side was intact, and no very notable 
difference of temperature was observed between the healthy and the 
paralyzed sides. 

" The patient died May 17th, after symptoms of acute peritonitis. 

" Autopsy. — Cancer of the stomach, circumjacent abscess, purulent 
peritonitis. 

" No exterior deformation of the cranium ; on the left side its walls 
were thick, doubly and triply so at some points ; the frontal sinus ex- 
tended to the left of the mesial line, and communicated with a large 
cavity situated in the orbital arch, which was composed of two thin 
osseous lamellae. 

" The left middle fossa was smaller than the right, and the right 
cerebellar fossa was smaller than the left. 

" The dura mater being incised, a large quantity of serum escaped 
from* the left side. The left hemisphere was very small, shriveled, and 
in length and breadth scarcely two-thirds the corresponding dimensions 
of the right hemisphere. The convolutions were pressed together, were 
hard, and of a whitish color. 

" On the external face of the middle lobe, behind the posterior mar- 
ginal convolution, and on the prolongation of the fissure of Sylvius, 
there was a deep depression running upward and backward, and three 
or four centimetres in length. At the bottom of this depression the 
convolutions were reduced to little ridges, which were hard, and of a 
yellow color. 

" The ventricle was considerably dilated ; the corpus striatum did 
not appear to be perceptibly diminished in volume, but the optic thala- 
mus was hardly one-fourth as large as that of the opposite side. 
There was considerable atrophy of the left crura of the fornix, and of 
the mammary tubercle. 

" The olfactory and optic nerves of the left side were apparently 
healthy ; the tubercular quadrigemina were not atrophied. 

" The right hemisphere was healthy. 

" The right hemisphere of the cerebellum and the middle cerebellar 
peduncle of the same side were atrophied." 

Examined with the microscope, the indurated convolutions of the 
left hemisphere presented an enormous quantity of amyloid corpuscles 
and of nuclei of connective tissue : 

The following cases I select from others of similar character which 
have occurred in my own practice : 

Case I. — J. S., a boy, aged five years, was brought to me in the 
autumn of 1869, to be treated for epilepsy. The paroxysms occurred 



278 DISEASES OF THE BRAIN. 

several times a day, and had originated when the child was two years of 
age, in consequence, as the mother thought, of a fall. 

At that time he could say a number of words, and was rapidly learn- 
ing to talk ; his intelligence was good, and he had been walking for 
several months. 

But after the first convulsion he ceased to speak and to walk, though 
he continued up to the time I first saw him to give his attention to very 
striking objects, such as noisy tops, bright-colored articles, and, above 
all, music and soldiers. During this period he had at least six exacer- 
bations, characterized by pain in the head, repeated convulsions, and 
coma. 

When he was about two years and a half old it was observed that 
he did not move the left arm and leg so freely as the right, and soon 
afterward he ceased to move them at all. The toes then began to be 
drawn under the sole of the foot, and the heel was raised. Then the 
leg became flexed on the thigh, and soon afterward the fingers of the 
left hand and thumb were gradually bent so as to press strongly against 
the palm. The wrist followed, and then the forearm. Both limbs were 
greatly atrophied. 

When he came under my examination he was having epileptic con- 
vulsions, both of the grand and petit mal, every day. There was no 
deformity of the skull, though it was certainly small for his age. His 
mind was feeble, and he did not give attention to any remarks made to 
him, but bright objects at once attracted his gaze, and he made efforts 
to get hold of them. 

I examined the fundus of the eyes with the ophthalmoscope, and 
discovered an anaemic condition of the retinas and atrophy of both 
optic disks. 

I gave it as my opinion that the child was suffering from diffused 
cerebral sclerosis, involving the left hemisphere ; * and that there was 
scarcely any prospect of material amelioration in his mental or physical 
condition. 

Case II. — A female, aged eight years, entered the New York State 
Hospital for Diseases of the Nervous System, June, 1870, having pre- 
viously been a patient at my clinic at the Bellevue Hospital Medical 
College. When quite an infant she had suffered from epileptiform con- 
vulsions, which had been almost immediately followed by paralysis of 
the right upper and lower extremities. The convulsions recurred at 
short intervals, and atrophy of the paralyzed limbs, with contractions 
of the fingers, hand, and forearm, supervened. She learned to walk, 
however, quite well, and also to talk without any very notable defects. 

Her mind was weak, and she was extremely silly in her behavior; she 
had never learned to read. 

Under the use of the bromide of potassium her epileptic paroxysms 
ceased, but the contractions and atrophy of the right arm resisted 



DIFFUSED CEREBRAL SCLEROSIS. 279 

treatment by galvanism and mechanical appliances. The leg acquired 
much more power under the treatment than it had previously possessed. 

Case III. — W. W., a gentleman, aged forty-three, came to me, De- 
cember 11, 1869, to be treated for what his physician and friends regarded 
as softening of the brain. 

About six months previously he had experienced, on awaking in the 
morning, great difficulty in extending the left hand and fingers, and 
through the whole day there was a decided tendency manifested for the 
latter to close, and the hand to be flexed upon the forearm; and this 
gradually, day after day, became stronger, till at last neither the hand 
nor fingers could be extended. 

Then the corresponding lower extremity became involved in a similar 
manner, and, about a month after noticing the first symptom, he had 
an epileptiform convulsion, and this was repeated twice the following 
day. Since then the fits have occurred at intervals of four or five days. 
With the contractions in the limbs of the left side, there was gradually- 
advancing paresis until, when he came under my observation, both arm 
and leg were almost completely paralyzed. Atrophy of both extremi- 
ties was present to an extreme degree, and sensibility and electro-mus- 
cular contractibility were almost entirely abolished. 

His mind was also notably impaired. He laughed immoderately at 
every question I put to him, and had a decided expression of imbecility. 
His speech was not affected to any remarkable degree, except as regarded 
extreme slowness of utterance. He had, previously to his illness, been 
a ready and quick speaker. My diagnosis was diffused cerebral sclero- 
sis, and I gave an unfavorable prognosis. The treatment, w T hich will be 
considered under its proper head, was, however, successful to a very con- 
siderable extent. 

It will be seen, from the foregoing account of the symptoms, that 
diffused cerebral sclerosis is characterized mainly by weakness of intel- 
lect, paralysis, and muscular contractions. 

Causes. — The predisposing causes of the affection under considera- 
tion are not thoroughly understood. The disease appears to be much 
more frequent in infancy, although it lasts to the period of old age, and 
sometimes originates at an advanced time of life. 

The exciting causes are likewise imperfectly known. Injuries of the 
skull from falls or blows, and hemorrhagic cysts, appear to have some 
influence in originating the disease, but more generally it is developed, 
so far as we can perceive, spontaneously. 

Diagnosis. — The diagnosis of diffused cerebral sclerosis must always 
be more or less uncertain, for the reason that the symptoms are met with 
in other very different affections. In children a similar set of phenom- 
ena may be the consequence of arrest of development in the brain with- 
out any alteration of its structure recognizable by our means of obser- 
vation. In the case of an idiotic child affected with convulsions, hemi- 



280 DISEASES OF THE BRAIN. 

plegia, and muscular contractions, I found, on post-mortem examination, 
the left hemisphere markedly smaller than the right, but I could detect 
no change of any part of its structure. 

Symptoms like those met with in diffused cerebral sclerosis may re- 
sult from brain-tumors of various kinds. 

In adults the disease is readily discriminated from cerebral hasmor- 
rhage and embolism by the gradual character of its advance, and by the 
mental symptoms being more strongly pronounced. But from soften- 
ing the diagnosis cannot always be made out, and an opinion must be 
formed from the history and phenomena in each individual case. 

From thrombosis the diagnosis is equally difficult. Perhaps the dis- 
tinction may be made both as regards softening and thrombosis by the 
facts that, though contractions are met with in both these diseases, they 
are not such invariable accompaniments as they are in diffused cerebral 
sclerosis, and that they are never, as occasionally in the latter affection, 
a primary symptom. 

Prognosis. — The prospect of complete recovery is very gloomy, and 
even amelioration has hitherto been regarded as out of the question. I 
am inclined, however, to think, as the result of my own experience, that 
the condition of patients, apparently suffering from the affection in 
question, may be decidedly improved by suitable medical treatment. 
I have several times succeeded in arresting the convulsions, strength- 
ening the mind, increasing the strength and sensibility of the paralyzed 
members, and relaxing the contractions. My success has been much 
more decided in cases which had originated late in life — probably, for 
the reason mainly that the disease was seen earlier in its course. 

Morbid Anatomy. — This division of the subject has already been con- 
sidered incidentally, to some extent, in the remarks made under the 
head of symptoms, and in the detail of cases quoted. 

The most obvious feature detected by ordinary observation is the 
increased hardness and density which the cerebral tissue has acquired. 
This generally occupies a considerable portion of one lobe, or may ex- 
tend through the whole of it, or may even affect a whole hemisphere. 
It is not distinctly circumscribed, but diminishes in intensity from the 
centre to the periphery, and, according to Pinel, never invades the gray 
substance. 

The increased density is attended with atrophy when the disease 
affects the adult, and with atrophy and arrest of development when 
children are its subjects. 

In order to understand the essential nature of the morbid process 
which causes the brain to become indurated, a few words in regard to 
cerebral histology are necessary. 

Besides the nervous tissue of the brain, there is another anatomical 
element present which fulfills the function of binding the cells and fibres 
together, and giving the whole substance its normal degree of consist- 



DIFFUSED CEREBRAL SCLEROSIS. 281 

ence. According to Virchow, 1 this, although analogous to, is different 
in some respects from ordinary connective tissue. He gave to it the 
name of neuroglia or nerve-cement. 

Diffused cerebral sclerosis consists in the hypertrophy or increased 
formation of this tissue, and the atrophy or disappearance of the proper 
nervous substance. Atrophy of the brain may, however, be due to 
other causes than sclerosis, as in the case reported with great minute- 
ness by Schroeder van der Kolk, 2 and several of those cited by Lalle- 
mand, 8 Turner, 4 and other writers. 

Pathology. — The symptoms which result from diffused cerebral scle- 
rosis are those which we might expect to be the consequence of a con- 
dition which essentially consists of a disappearance of that part of the 
brain-tissue capable of producing or transmitting nervous force, and the 
substitution of another histological element which is of secondary im- 
portance. They all indicate deficient cerebral power. It is with the 
brain as with a muscle undergoing atrophy : less force results from its 
action in correspondence with the advance of the process by which the 
characteristic anatomical elements disappear. 

Doubtless, if we had the opportunity of more thorough study of 
the symptoms of diffused cerebral sclerosis, and comparing them with 
the condition of the brain as found by post-mortem examination, we 
should find that they varied considerably in character, according to the 
part affected, and we should probably have reason to believe that the 
nerve-cells which had disappeared — motor, sensitive, or trophic — were 
in exact pathological relation with the symptoms observed. This spe- 
cial point has been well studied by MM. Duchenne de Boulogne and 
Jouffroy, 6 in a recent paper, devoted to a somewhat different disease, 
and to which I have recently been enabled to add a few important 
data. 

Treatment. — This division of the subject has scarcely received any 
attention from authors. My experience, however, has sufficed to con- 
vince me that we can occasionally improve the condition of the patient. 

If there are epileptic convulsions, they may be prevented by the ad- 
ministration of the bromide of potassium, in doses of at least twenty 
grains, three times a day, to an adult. Larger doses may be necessary. 
On the cessation of the convulsions, it will sometimes be found that the 
intelligence at once begins to be developed. 

The paralysis and contractions may sometimes be lessened by the 

1 " Cellular Pathology," Chance's translation, London, 1860, p. 2?7. 

2 " A Case of Atrophy of the Left Hemisphere of the Brain," etc. New Sydenham So- 
ciety Translation, Lon'Ion, 1861. 

8 Op. cit. 

4 " De l'atrophie partielle ou unilaterale du cervelet," etc., Paris, 1856. 
6 " De l'atrophie aigue et chronique des cellules nerveuses de la moelle et du bulbe 
rachidien," etc. : Archives de Physiologie, No. 4, Juillet et Aoiit, 1870, p. 499. 



282 DISEASES OF THE BRAIN. 

persistent use of both the induced and primary galvanic currents. The 
first named will often in the beginning fail to act upon the muscles, in 
which case the latter should be employed. This is always better for 
the contracted muscles than the induced current. For the relief of 
the paralysis it should be interrupted, for the relaxation of contrac- 
tions it should be constant. 

As regards the central lesion, I think it may occasionally be reached, 
when it has not had time to become very extensive or profound. And 
the best and really only means I know of are, the primary galvanic 
current passed through the brain, and the administration of the iodide 
of potassium, which unquestionably has the power of preventing the 
formation of new connective tissue. 

In using the galvanic current, the electrodes — wet sponges — should 
be applied over the mastoid processes, and kept there for a period not 
exceeding three minutes. From three to eight milliamperes, according 
to the size of the electrodes, will be sufficient. The application should 
be made about every alternate day. 

I am unable to say that these measures have actually removed the 
supposed sclerosis of the brain, and caused the reformation of the atro- 
phied cells, but I am very sure that symj)toms such as are attendant 
upon diffused cerebral sclerosis have several times been measurably dis- 
sipated by its influence. Thus, in the third case mentioned as occurring 
in my practice, the mind improved, the epileptic paroxysms ceased, the 
contractions were relaxed, the paralysis lessened, the affected limbs in- 
creased in size, and the further progress of the disease was arrested. 
At the present date (December 30, 1870) the gentleman is able to take 
care of himself, to walk tolerably well, and to use the formerly-para- 
lyzed arm for many purposes. In three other cases a like treatment 
has been productive of almost as marked a degree of benefit. 



CHAPTER XIII. 

PARALYSIS AG I TANS. 



It is only of late years that the affection in question has been par- 
tially recognized as a distinct pathological condition, associated with 
certain symptoms. These symptoms were formerly, and still are to a 
great extent, confounded with other groups similar in several promi- 
nent features, but different altogether in anatomical relations, normal 
and abnormal. 

Thus, under the designation of paralysis agitans, were comprehended 
the phenomena due to multiple cerebral sclerosis, multiple cerebro- 
spinal sclerosis, and muscular agitation, general or local — the result of 



PARALYSIS AGITAXS. 283 

very dissimilar lesions, or without discoverable morbid changes of any 
kind — the one symptom of tremor sufficing to bind them together. 
Even by late writers the distinction is not clearly made out. 

It is, in the present state of our knowledge, impossible to say in 
all cases what part of the intra-cranial mass is affected. Still, we 
are not altogether without data on this point, and an attentive con- 
sideration of the symptoms will often, at least, enable us to say what 
ganglion of the encephalon is the main seat of the lesion. But, 
mindful of the fact that this work is intended to be practical, I shall 
not venture to deal with pathological refinements, but will point out, 
with as much succinctness as possible, one form of the morbid process 
under notice — a form which I think I am enabled to describe, from 
my own observations, with considerable accuracy. That form has 
been designated — 

PARALYSIS AGITANS. 

Symptoms. — Among the first symptoms noticed in this affection is 
pain, which occurs in sharp paroxysms of short duration. Sometimes 
the sensation is as instantaneous as an electric shock. It is rarely the 
case that there is any extreme constant pain experienced, though a 
feeling of fullness or constriction is occasionally more or less perma- 
nent. 

In a few cases the first observed symptom has been an epileptic 
paroxysm. 

It is not uncommon to meet with disorders of sensibility in other 
parts of the body; and these may either be anaesthetic or hyperaesthetic 
in character. Probably the most common is a numbness of the ends 
of the fingers or toes, which gives the sensation of cushions when ob- 
jects are touched, and which is generally confined at first to a single 
upper or lower extremity. Shooting pains, something like electric 
shocks, are also sometimes experienced. The progress of the disease is 
almost invariably slow, and hence several months may elapse before any 
disorders of motility are experienced. These, however, are the next 
symptoms to make their appearance, and are generally first manifested 
by the occurrence of tremor or trembling. 

Tremor usually, but not always, is gradual in its development, and 
may be restricted to narrow limits. It may at first only be felt when 
the patient is unusually quiet, and has not his attention engaged. Thus 
a gentleman told me he had, for several months, only been sensible of 
a vibration in his arm when he lay down at night. It was then — from 
the description he gave me — limited entirely to the extensor indices of 
the left hand, and was, in the beginning, not strong enough to move 
the finger. When I first saw him, several years afterward, both arms 
and one leg were strongly agitated. 

In another case, which I saw almost from the very beginning, the 



284 DISEASES OF THE BRAIN. 

tremor was restricted to the same muscle for several months, and then 
gradually involved the extensors and flexors of the hand. And in sev- 
eral other instances which have come under my notice, the onset was 
equally gentle. But, as I have said, this is not always the case. A gen- 
tleman consulted me in the summer of 1870, who, after having ex- 
perienced severe darting pains in the head and through the limbs on the 
right side, was suddenly, while in his field overlooking some work, seized 
with a violent trembling of the right hand, which continued for several 
minutes, notwithstanding his efforts to prevent it. A few days subse- 
quently, he had another accession of a similar kind in the same limb, 
and by degrees the intervals became shorter, until, in the space of a 
month, the tremor was constantly present except when he slept, and, 
when I saw him, had extended to the whole arm, and to the lower ex- 
tremity of the same side. 

In another case, a gentleman, much addicted to excessive mental 
exertion, was awakened one morning by a violent agitation in his right 
foot. He had been under my care several months previously for severe 
headache and inability to sleep, for which, believing them to result from 
inordinate intellectual labor, I had recommended mental rest and horse- 
back exercise. Under the use of these measures he had apparently quite 
recovered, but against my advice had resumed his literary labors. 

He was not very confident how long the shaking of the foot had 
lasted, but thought it was not more than a few seconds. 

Several days afterward, while writing, his right hand began to trem- 
ble slightly. He ceased his occupation, and rubbed his hand with the 
other. The tremor stopped for a moment only, again began, and has 
scarcely ever since been absent. The whole side eventually became 
involved. 

The tendency of the tremor is always to extend. Beginning in an 
extremity or a group of muscles, or only in a single muscle, it goes on 
attacking others, until at last all the limbs and even the head may be- 
come affected. By preference, the advance of the tremor is lateral, 
that is, if an arm be first invaded, the leg of the same side next suffers, 
then the other arm, and then the corresponding leg. Usually the head 
is the last part attacked; but this is not always so, as I have seen sev- 
eral cases in which the trembling began in it. 

For a long time the tremor is to some extent under volitional con- 
trol. A patient, for instance, will slap his tremulous hand on his knee 
and for a few seconds can manage to keep it quiet, but it soon begins 
to shake again, and, though perhaps a second time he may arrest its 
movements by a like process, the period of rest is shorter. Any change 
of position is calculated to quiet the tremor for a time, and thus the 
patient is every few minutes moving his arms or legs in the attempt to 
get a little respite. 

It is always increased by emotional disturbance of any kind. A 



PARALYSIS AGITANS. 285 

limb which may ordinarily be but slightly tremulous, will shake vio- 
lently from the excitement or anxiety produced by making a visit to a 
physician. The effort to keep it quiet will also often increase the tremor. 

For a very considerable period after the beginning of the disease, the 
shaking ceases during sleep, but eventually this state affords no respite, 
and the patient is thus deprived still further of his physical strength. 

It is not often the case that the muscles of the face are affected very 
early in the disease, but they frequently become involved at a later 
period. In several cases I have seen a constant tremor in the upper 
eyelid of one or both sides, and in one instance this was the first mani- 
festation of the disease. 

In another very remarkable case the first indication of tremor was 
perceived in the left eyeball, which was, by clonic spasms of the inter- 
nal rectus muscle, kept in a state of motion producing a kind of nys- 
tagmus. The upper lid of the same eye next became affected, and then 
the tremor appeared in the corresponding arm. The upper lip I have 
several times seen tremulous, causing thereby an indistinctness in the 
articulation. 

I have never observed other muscles supplied by the facial, or third 
nerve, to be involved in the tremor. 

Occasionally the lower jaw is rendered tremulous from the seat of 
the disease being at the origin or in the course of the fifth nerve. 

The tongue is sometimes affected with tremor, generally at first on 
only one side, and I am inclined to think that the muscles of the phar- 
ynx and larynx do not invariably escape. 

The tremor is not, as some authors have asserted, only manifested 
when voluntary movements are performed. This is probably the case 
at least in the first instance with multiple cerebrospinal sclerosis, but 
it certainly is not in the disease now under consideration. Jaccoud 1 
calls attention to the error which has been committed relative to this 
point, and my own experience is uniformly in support of the opinion 
he expresses. 

The next symptom of importance to make its appearance is paraly- 
sis ; and, as the lesion is limited to the hemispheres or begins in them, 
it always follows the tremor. On this point I have insisted in my 
lectures to the class of the Bellevue Hospital Medical College, as an 
important indication of the fact that paralysis agitans is always a cere- 
bral disease, and I am glad to find so exact an observer as Jaccoud 2 
asserting that the paralysis is often preceded by muscular agitation or 
trembling. 

At first the loss of power is slight, and, like the trembling, is limited 

to a single muscle or group of muscles, but it gradually extends urtil 

it involves the limbs of one side, or even of both sides. According to 

my observations, it follows the course of the trembling, no limb being 

1 "Traite de pathologie interne," p. 194. 2 Op. et loc. cit. 



286 DISEASES OF THE BRAIN. 

ever paralyzed till it has for some time been affected with tremor. 
In the face, however, the paralysis appears to be independent of the 
tremor. 

The period which elapses between the appearance of the tremor and 
the accession of the paralysis varies in different patients, and even 
greatly in the same patient. Thus some muscles may exhibit notable 
loss of power in a few weeks after they have begun to be agitated, while 
others remain free from paresis for many months. 

When the loss of power affects the extensors or flexors — especially 
in the former event — contractions may take place, as in diffused cere- 
bral sclerosis, and the limbs are thus more or less distorted. The most 
common seat of this phenomenon is in the upper extremity, and it gen- 
erally begins in the fingers, extending gradually to the wrist and elbow. 
But in some cases, even though the antagonism between certain groups 
of muscles be destroyed, there are no contractions. The muscles of the 
head, face, and trunk, do not escape. Strabismus, ptosis, and facial 
paralysis, are thus produced, and the muscles concerned in speech, in 
deglutition, and in respiration, likewise become involved. The sphinc- 
ters, according to my experience, are rarely paralyzed in the early stages 
of the disease, but I have several times witnessed paresis of the bladder 
among the primary symptoms. 

A marked symptom which I have observed, and which can only be 
distinctly shown by means of the dynamograph, is the inability of the 
patient to maintain a continuous muscular contraction, for even a short 
period. I have noticed this as among the very first indications of 
paresis, and I am disposed to think it exists even before the tremor 
is noticed. Thus, a gentleman occupying a prominent public posi- 

Fig. 18. 



tion, and in whom I had diagnosticated paralysis agitans, instead of 
making a straight line with the pencil of the instrument, traced one 
of which Fig. 18 is a facsimile. Repeated efforts only gave worse 
results. 

In another case, that of a gentleman referred to me by my friend 
Dr. Yan Buren, the line made was as shown in Fig. 19. Here the 
patient was able to maintain the contraction at its original force for 
only about the sixth of a minute — the time required for the paper to 
traverse the pencil being exactly half a minute, and a third part of the 
line being horizontal. 



PARALYSIS AGITANS. 287 

The ability to coordinate the affected muscles is always impaired, 
and thus in voluntary movements there is agitation independently of 

Fig. 19. 



the esoteric tremor. This is seen not only in active movements, but in 
passive muscular contractions, such as those by which an article is held 
in the hand. In such a case the fingers cannot be kept in apposition 
with the object, but are moved about in a disorderly manner. The 
incoordination is manifestly connected with the inability to maintain a 
lengthened muscular contraction to which reference has just been made. 

Sometimes, by the strong effort of the will, assisted by the sense of 
sight, these last two difficulties may for a little while be overcome. A 
gentleman now under my charge, suffering from the affection in ques- 
tion, cannot, for instance, carry a glass of water to his lips except by 
looking at it fixedly, and concentrating all his volitional power upon 
the act. His lower limbs are not yet affected, and he consequently 
can coordinate them, in walking and other movements, perfectly well. 

In another case, a lady, affected with paralysis agitans, undertook 
to help her invalid husband to rise from his chair ; a band of music 
happening to pass the window, she turned to look at it, and, at once 
relaxing her hold, let him fall to the floor and injured him severely. 

Zenker 1 reports a case in which there was a similar loss of the ap- 
preciation of the state of the muscle ; and another is mentioned by 
Reynolds, 2 under the head of "muscular anaesthesia." I am very sure 
that many cases of this last-named affection are instances of paralysis 
agitans, and I shall presently more specifically refer, under a differ- 
ent head, to two remarkable cases which have occurred in my own 
experience. 

Another phenomenon closely related with this incoordination is gen- 
erally present in paralysis agitans, and that is, that the patient loses 
that innate or early-acquired knowledge of the exact situation of the 
several parts of his body. We can all of us, not thus affected, close 
our eyes, and touch, with the end of the finger, any particular point on 
the face or rest of the body, with the utmost exactness. But a person 
with paralysis agitans cannot do this. Thus, in attempting, with the 
eyes shut, to place the end of the index-finger on the middle of the 
eyebrow, he misses that point, sometimes by as much as two inches ; 
and no matter how frequently he tries, he succeeds no better. It 
would appear that, in such cases, the normal instinct of topographical 

1 " Ein Eeitrag zur Sklerose des Hirns und Riickenraarks," Henle und Pfcufer's 
Zeitschrift fur rationelle Medizin, Bd. xxiv., 1865. 

2 " System of Medicine," vol. ii., p. 330. 



288 DISEASES OF THE BRAIX. 

relation between the fingers and the cutaneous surface generally, which 
all persons and many animals seem to possess, is impaired. This is 
termed the "muscular sense." 

The electro-muscular contractility is never, according to my ex- 
perience, diminished in paralysis agitans, uncomplicated with similar 
lesions in the spinal cord. 

The attitude and gait of a person affected with paralysis agitans 
are peculiar. In standing, the body is generally inclined forward, the 
head falling toward the chest, the trunk flexed at the pelvis, and the 
knees slightly bent. In walking, the action is similar to a jog-trot, the 
body being still inclined forward, and the patient often moving with 
considerable rapidity. I have had several persons with the disease 
under my charge who could not walk at all, but who could run with 
surprising agility. One of these, a gentleman advanced in life, sent to 
me by my friend Prof. Sayre, was unable to take a step in my consult- 
ing-room. He was carried down-stairs by his attendants with some 
difficulty, and when he reached the front-door he was put on his feet. 
He then told his servant to give him a push, which the man did with 
all his might, and the old gentleman, being started, went at a full run 
and jumped into his carriage without the least difficulty. This con- 
dition is known as "festination." . 

There is often a strong tendency to plunge forward, and at times 
there is an impossibility of controlling it except by catching hold of 
some fixed object. Kot long since I was walking down Broadway, 
when I saw in front of me a gentleman who was then under my charge, 
and in whom I had diagnosticated paralysis agitans. Although aware 
of his peculiar impulsive gait, I had never seen it so strikingly mani- 
fested as it was then. He went at a full trot, threading his way among 
the numerous people in the street, until, apparently exhausted, he 
would lay hold of a lamp-post or awning-post and cling to it till he 
had recovered his breath, to start off again in a similar manner. 

This impulsion of the bbdy forward makes it easy for the patient to 
ascend a staircase, but, on the contrary, very difficult to go down one. 

The first case of the disease in question which I saw in this city, 
over six years ago, was characterized by an extreme degree of festina- 
tion. It was that of a maiden lady, over fifty years of age, who had 
been affected for several years. When she was going up-stairs no one 
could perceive the least irregularity in her gait, but to go down was 
impossible. 

Sometimes, however, the tendency is to go backward. This was 
the case, to a remarkable extent, in a gentleman, a resident of this 
city, who was sent to me by Prof. Van Buren. Every time he rose 
from his chair he was forced to take several steps backward, and it was 
only by constant mental effort that he was able to go forward at all. 

The tactile sensibility is generally impaired from a very early 



PARALYSIS AGITANS. 289 

period in the course of the affection, and thus the two points of the 
aesthesiometer must be more widely separated than in the normal con- 
dition of the system, in order to get two separate impressions. This 
anaesthesia bears no necessary relation to the region of skin covering 
the affected muscles. According to my experience, it is most marked 
at the terminal extremities of nerves. 

Numbness of different degrees, pains of various kinds, increased 
or diminished temperature, and excessive hyperesthesia of the skin, 
may also exist. 

As paralysis agitans is purely a cerebral affection, the " knee-jerk " 
will be found to be normal, and the ankle-clonus cannot be obtained. 
In cases where the knee-jerk is increased and the ankle-clonus is pres- 
ent there is reason to believe that the antero-lateral columns of the 
cord have become affected either secondarily or independently. 

The special senses may be affected to a variable extent. Thus 
there may be amblyopia, or even complete blindness ; the taste is very 
often impaired or abolished, and the hearing rendered less acute. 

The ophthalmoscope should always be employed to examine the 
fundus of the eye. The condition generally found to exist is white 
atrophy of the optic disk, which is identical in general features with 
sclerosis. The vessels of the retina will usually be found small, the 
branches of the veins few in number, and the choroid of a paler hue 
than is natural. 

The course of paralyis agitans is progressive. 

The patient is finally unable to walk, the friction of his shaking 
body against the bed abrades the skin, the dejections are passed in- 
voluntarily, and he dies either in coma, in convulsions, or by a gradual 
process of asthenia, his mind participating in the general decay. The 
duration of the disease varies from a few months to eight or ten years. 
Generally it runs its course in about five years. 

Causes. — Age is certainly one of the most powerful predisposing 
causes of paralysis agitans. Thus, of thirteen cases in which I diag- 
nosticated the disease in question, all were over fifty years of age, and 
six were over sixty. I have seen numerous cases of paralytic tremor 
in younger persons, but the morbid condition had scarcely any points 
in common with that now under notice. Cases, however, are on record 
in which young persons were the subjects. There is some evidence to 
support the theory that it is sometimes hereditary, but the whole sub- 
ject is so confused in the minds of most authors that it is difficult to 
make out clearly what they refer to under the designation of paralysis 
agitans. Of the thirteen cases occurring in my own practice, private 
and hospital, five had immediate ancestors who had suffered from 
some form of tremor and paralysis. Whether the lesion was purely 
cerebral, cerebro-spinal, or whether the disease was entirely functional, 
I was not able to decide from the information given. 
20 



290 DISEASES OF THE BRAIN. 

The influence of sex is more readily ascertained and is very evi- 
dent. Eleven of my cases were males and only two females. 

Of exciting causes there are many. In two of my cases it followed 
immediately on attacks of scarlet fever, in two it was a sequence of 
typhoid fever, in two it ensued after rheumatism, in two it was prob- 
ably syphilitic, in two it was apparently excited by great emotional 
disturbance, in one by inordinate muscular exertion, and in three no 
cause could be assigned, or at least there was not, in my opinion, any 
sufficient exciting cause to be discovered. 

Diagnosis. — Paralysis agitans has heretofore been confounded with 
other diseases, and its very existence as an independent affection is 
very illogical] y questioned by some writers. 

The occurrence of " head-symptoms " is sufficient to diagnosticate 
paralysis agitans from functional tremor, which is never a very serious 
affection, and the seat of which is not always centric. Besides, in the 
latter there are no festination, alterations of sensibility, incoordina- 
tion, muscular anaesthesia, or inability to maintain a continuous muscu- 
lar contraction, while the paper of the dynamograph traverses the 
pencil of the instrument. The functional disorder is more liable to 
occur in persons under fifty than in those over that age. From the 
cerebro-spinal form of multiple sclerosis, which will be fully consid- 
ered in another section of this work, it is distinguished mainly by the 
facts that the tremor makes its appearance before the paralysis, and 
that the agitation is present whether voluntary movements are being 
made or not. 

With the purely spinal form it is not likely to be confounded by 
any one paying the slightest attention to the phenomena of the two 
diseases. 

From chorea it might in some cases not be readily discriminated 
without a thorough study of the clinical history and existing symp- 
toms. But, though chorea sometimes occurs in adults, and is gener- 
ally accompanied by "head-symptoms," the two affections possess few 
other phenomena in common. 

In the first place, the mental symptoms in chorea are indicative of 
feebleness from the very first, while in paralysis agitans imbecility 
supervenes late in the course of the disorder. In chorea there are no 
vertigo, pain in the head, or other evidences of congestion, while in 
the disease under notice these are among the very earliest symptoms. 
In chorea there is no actual tremor, but the disorderly movements are 
more extensive and irregular than in multiple cerebral sclerosis ; nei- 
ther is there festination or bending of the body forward. 

Tremor is sometimes met with after cerebral haemorrhage or other 
cause producing hemiplegia, but in such cases the clinical history, and 
the fact that the trembling comes on after the paralysis, will suffice to 
render the diagnosis sure. 



PARALYSIS AGITANS. 291 

Prognosis. — The prospect of recovery is always unfavorable, but 
not, I am induced to think, absolutely hopeless if the patient be seen 
sufficiently early in the course of the disease and submitted to proper 
medical treatment. The probability of an arrest of the onward ten- 
dency is by no means small under like circumstances. Still, in the 
great majority of cases, all means fail, and the affection gradually and 
persistently goes on to its termination — death. 

Morbid Anatomy. — So many and widely different lesions have been 
discovered by competent observers, both in the brain and in the 
spinal cord, in cases of paralysis agitans, that we are forced to admit 
that the precise seat of the leision is as yet unknown. In a number 
of instances no lesion has been discovered at all. In a case of my 
own, a man who had been under my observation for eight years, and 
who was a typical example of the disease, not the slightest lesion 
could be discovered in the brain or cord, although careful gross and 
microscopical examinations were made. Death followed soon after 
the appearance of bulbar symptoms. There were difficulty in swal- 
lowing, feeble respiration, and irregular and weak heart, and finally 
death ensued, evidently from paralysis of the pneumogastric, and yet 
no lesion could be discovered either in the medulla, basal ganglia, or 
cortex. Unquestionably there was a lesion, but the methods of ex- 
amination such as we possess at the present day were inadequate to 
discover it. Similar cases are reported by Charcot, Berger, Westphal, 
Ordenstein, Heimann, and others. In the majority of instances lesions 
have been discovered, but they were not, by any means, limited to 
one region of the brain. Thus, such lesions as softening, sclerosis, and 
tumors involving the cortex, the thalami and striati, the pons, the me- 
dulla, and the internal capsule, have been observed at various times. 
Atheromatous degenerations of the blood-vessels is not uncommon, 
and in many cases spinal lesions — such as lateral sclerosis, degenera- 
tion of Clark's columns, and meningitis — constitute the only apparent 
morbid changes. 

Strumpel and Gauthier both advance the theory that paralysis agi- 
tans is primarily a muscular affection, without, however, in my opin- 
ion, having any good reason for so doing. 

Pathology.-— From the fact that the lesions resulting in paralysis 
agitans, when they are discovered at all, are so inconstant and diverse, 
it naturally follows that the pathology must be mainly speculative. 

Now, in my opinion, Parkinson 1 has described two very distinct 
affections under the name of paralysis agitans. One of these is cer- 

1 "Essay on the Shaking-Palsy," London, 1817. In the previous editions cf this 
work I have referred to my inability to obtain a copy of Parkinson's work, and that my 
citations from it were therefore necessarily second-hand. Observing this statement, Dr. 
T. Windsor, of Manchester, England, was kind enough to present me with a copy, so that 
I am able in the present edition to refer to Parkinson directly. 



292 DISEASES OF THE BRAIN. 

tainly functional so far as this : that the tremor shows no disposition 
to extend to distant parts of the body, that it is the only symptom 
present, that no lesion has been discovered, and that it is readily cured. 
The cases described by him, on pages 48 and 50 of his " Essay," were 
of this form, and Case IV. was probably of like character. The 
other is characterized by the phenomena which I have detailed in this 
chapter, and which, though imperfectly described by other authors, 
have either been confounded with multiple cerebro-spinal sclerosis, or 
regarded as constituting an aggravated form of the functional dis- 
order. 

Parkinson defines it as " involuntary tremulous motion, with 
lessened muscular power, in parts not in action and even when sup- 
ported ; with a propensity to bend the trunk forward, and to pass 
from a walking tc a running pace, the senses and intellect being unin- 
jured." 

Ordenstein 1 is of the opinion that the true anatomical lesion of 
non-spinal tremor is yet to be found, although he refers to several 
cases in which there were organic changes in the pons Varolii, me- 
dulla oblongata, and crura cerebri. These he regards as accidental, 
and therefore as not being essential features of the disease. It is 
scarcely necessary to say that he does not make the distinction be- 
tween multiple cerebral sclerosis and the form of tremor to which I 
restrict the name of paralysis agitans, and the morbid anatomy of 
which is still undetermined. 

The only two theories in regard to the pathology of this disease 
which are entitled to serious consideration are, on the one hand, that 
it is of cerebral origin ; on the other hand, that the morbid changes are 
to be looked for in the spinal cord. In regard to the latter theory, 
although paresis, rigidity, and various sensory anomalies frequently 
accompany spinal lesions, tremor does not ; nor are festination, scan- 
ning speech, and the emotionless expression of the face, symptoms 
which can be attributed to morbid conditions of the spinal cord. 

The " spinal theory " has again been quite recently advocated by 
Teissier, 2 who reports three autopsies where the only morbid condition 
observed was slight diffused sclerosis of the lateral columns, yet it 
seems to me that the entire train of symptoms point to a cerebral 
lesion affecting the motor tract, and that where the spinal cord is im- 
plicated it is either from an extension of the primary morbid process, 
or else is an independent disease. 

I have long been of the opinion that mobile spasm in any form is 
the result of irritation of cerebral motor nerve cells, but not of cerebral 
motor conducting fibres. Irritation of the latter is invariably followed 
by spastic spasm. The regions of the brain in which motor nerve 

1 "Sur la paralysie agitante," etc., Paris, 1868, p. 20 et seg. 

2 " Lyon med.," 1888, lviii. 



PARALYSIS AGITANS. 293 

cells are known to exist are the cortex, the striata, the medulla, and the 
pons, and irritative lesions in these regions is frequently followed by 
some form of mobile spasm. Hence it follows that the different 
varieties of mobile spasms, as exemplified in the movements of chorea, 
athetosis and convulsions, and in the different forms of tremor, are 
very closely allied one w T ith the other as far as their pathological 
origin is concerned. The difference in the external manifestations of 
the muscular movements indicates a difference in the degree or in 
the form of the central irritation. If this view is correct, the wide 
diversity of the cerebral lesions discovered in paralysis agitans can, in 
a great measure, be accounted for. In the majority of cases of paraly- 
sis agitans there are both tremor and rigidity. Therefore we would 
expect to find both motor nerve cells and conducting fibres implicated 
in the morbid process. Hughlings Jackson advances the theory that 
in paralysis agitans there is wasting of the motor nerve cells in the 
cortex in order from the smallest to the largest cells. This hypothe- 
sis, if it is made to include the cells of the corpus striatum and the 
pons, coincides accurately with my own views. The motor conduct- 
ing fibres must also be involved, to account for the spastic muscular 
condition. This would explain satisfactorily the slight diffused scle- 
rosis of the lateral columns observed by Teissier and others, for it is 
well known that degeneration beginning in the cerebral motor tract 
generally finds its way to the motor conducting path in the cord. 

The most probable theory, therefore, which would account satis- 
factorily, at least to my mind, for the symptoms of paralysis agitans 
is that of an irritative lesion affecting the motor nerve cells of either 
the cortex, the striata, or the pons, together with a greater or less de- 
generation of the motor conducting tract. 

Treatment. — To detail all the various methods which have been 
employed in the treatment of the group of symptons which I have 
classed together as paralysis agitans would be a fruitless piece of 
labor. Many of the cases of cure which have been reported were not 
instances of the disease now under notice, but of the milder and, so 
far as we know, functional disorder ; and therefore it would be use- 
less to adduce them as guides in the present connection. I shall 
therefore confine my remarks to the results of my own experience. I 
am very sure that the condition of the patient is generally improved 
by the administration of hyoscyamus. I generally employ Merck's 
hyoscyamine in solution in the proportion of one grain of the alkaloid 
to one ounce of water. Of this mixture, four drops three times a day, 
in water, after meals, may be given. The dose should gradually be 
increased by the addition of one drop a day until the toxic effects of 
the drug begin to be perceived. This will be manifested first by dry- 
ness of the throat. When this condition becomes apparent, the dose 
should be reduced to the original quantity, and then increased as in 



294 DISEASES OF THE BRAIN. 

the first instance. This plan of procedure should be repeated sev- 
eral times. 

By this remedy alone the tremor is often markedly diminished, and 
the paralysis and other disorders of motility and sensibility greatly 
lessened. 

Thus, in the case of a distinguished gentleman, a Senator of the 
United States, who consulted me in the spring of 1870 for what was 
designated shaking-palsy, but in whom I diagnosticated the disease 
under consideration, amendment was perceived from the very first day 
of the treatment. The tremor and paralysis diminished, the mind 
became stronger and more able to endure exertion, and the physical 
strength much increased. He was soon able to write and to attend to 
his official duties, and he has continued in his advanced stage of im- 
provement to the present date. He still, however, takes his medicines, 
and will probably be obliged to do so for a long time yet. 

In another case — that of a gentleman living in the interior of this 
State — no means have been so successful in improving the general 
health, and arresting the progress of the disease, as the preparation of 
hyoscyamine already alluded to. I have given this remedy, alone or in 
conjunction with others, in nine cases, and never without a decidedly 
favorable effect. 

Electricity is, however, a powerful adjunct, and I always employ 
it when the opportunity exists for so doing. The primary current, 
from not exceeding fifteen cells, should be passed through the brain 
antero-posteriorly and laterally, as previously described, and the sym- 
pathetic nerve should likewise be acted upon by a current of similar 
intensity. 

The tremulous muscles should also be subjected to the influence of 
a primary current of low tension. I am not sure that it makes any dif- 
ference in which direction the current be passed, but it is important 
that it should not be so intense as to cause any considerable pain. 

For the paralysis the induced current — not too strong— is to be 
recommended, and for any contractions that may be present it is the 
preferable form to use. 

A gentleman, over sixty years of age, from Tennessee, consulted 
me in September, 1870, for tremor associated with paralysis. His 
physician, Dr. W. W. Yandell, came with him, and gave me much 
valuable information in regard to the progress of the disease. In the 
first place, there had been, several years previously, symptoms of a 
disordered cerebral circulation, indicated by pain and vertigo. Soon 
afterward tremor supervened in the left hand, and gradually extend- 
ed to both limbs of that side. There were also paralysis and loss of 
sensibility. When he came under my notice, the upper extremity was 
more affected than the lower ; contractions had taken place, and the 
fingers were strongly pressed against the palm of the hand, the hand 



PARALYSIS AGITANS. 295 

was bent on the forearm, and the elbow was flexed to its utmost ex- 
tent. The limb was somewhat atrophied, but electro-muscular con- 
tractility was not sensibly impaired. 

The voice was exceedingly weak, but there was no paralysis of 
the tongue or facial muscles, and though the patient could not speak 
above a whisper, every word was articulated distinctly, and was ap- 
propriately used. The body was greatly bent forward, the attitude 
being that of a person ascending a steep hill, and there was decided 
festination. The tremor and paralysis were much more marked on 
the left side than the right, and the agitation was altogether inde- 
pendent of voluntary movements. 

The mind, except as regarded the memory, was not essentially im- 
paired, and the sight and hearing were unaffected by the disease. 
There had never been any convulsive attack or loss of consciousness, 
and the course of the disease had been extremely gradual. Ophthal- 
moscopic examination revealed nothing beyond an anaemic condition 
of the retinae and choroids. 

I diagnosticated paralysis agitans, probably involving also the right 
corpus striatum, and prescribed the tincture of hyoscyamus, and elec- 
tricity. The patient remained in New York a few days, and then re- 
turned to his home with the tremor abated, the contractions partially 
overcome, the muscles improved in strength, and the tendency to fes- 
tination lessened. 

A month afterward Dr. Yandell, who had continued the treat- 
ment, wrote me, of the patient, that the improvement was more de- 
cided than his most sanguine friends had anticipated, and still con- 
tinued ; that the agitation was scarcely perceptible ; that he could 
more than half extend the fingers of the left hand, could straighten 
his wrist and elbow, and could lift a chair, or put on his hat, with 
the right hand. From what I have since ascertained, he bids fair to 
recover entirely. 

If the general health be materially impaired, cod-liver oil, iron, 
and strychnia, may be administered with advantage. 

The food should always be highly nutritious, and a glass or two of 
wine, if not particularly contraindicated, may be taken daily with advan- 
tage. Passive exercise in the open air is always beneficial, but exces- 
sive walking or strong muscular exertion of any kind should be. care- 
fully avoided. Emotional excitement or mental labor must be rigidly 
avoided. 

Under the treatment thus indicated, the patient may at least be 
relieved of a great deal of his suffering. 



296 DISEASES OF THE BRAIN. 

CHAPTER XIV. 

TUMORS OF THE BRAIK 

Though tumors of the brain differ greatly in character, they all, 
when they are accompanied by any notable symptoms, present many 
features in common. It will therefore be convenient to consider them 
under one head, and point out their differences when the morbid anat- 
omy and pathology are discussed. 

Symptoms. — It is possible for a person to have a tumor of the brain 
as large as an orange, and present no symptoms of it during life. One 
such case came under my observation several years ago, and many oth- 
ers are on record. In the instance referred to, the patient, a teamster, 
was twice shot in a quarrel ; one ball grazed the skull, ploughing up the 
right parietal bone to the extent of an inch ; the other entered the left 
breast, wounding the heart. Death ensued almost instantly. The brain 
was examined, and a tumor of an elliptical form, two inches in its long 
diameter and one and three-quarters in its short diameter, was found, 
involving the white substance of the left posterior lobe. The character 
was that which Yirchow has since called gliomatous, and contained no 
nervous tissue. 

Again, it sometimes happens that tumors of large size exist in the 
brain, and produce no symptoms till a few days before death. Then 
very violent manifestations ensue, and the patient dies convulsed or 
comatose. And it is always the case that the symptoms are entirely 
different, as one or other part of the brain is involved, or the tumor is 
large or small. Thus, we know very well that a morbid growth, seated 
in the pons Varolii, will cause very diverse symptoms from those pro- 
duced by a similar formation in one of the anterior lobes of either of 
the hemispheres. AYe may say, in general terms, that tumors situated 
in the medulla oblongata, the pons, the optic thalami, the corpora 
striata, the crura cerebri, the cerebellum, and the convex surface of the 
hemispheres, give rise to more decided manifestations than when the 
white substance of the hemispheres is the seat. 

Pain is probably the first symptom which attracts attention. It is 
generally confined to a definite region of the head corresponding to 
the location of the disease, but this is not always the case. It may be 
either a dull ache, lasting the greater portion of the day, or a sharp, 
lancinating paroxysm, which ensues but for a few moments and re- 
curs frequently. As the morbid process goes on, the cephalalgia be- 
comes more severe, and finally reaches a stage of great intensity. So 
great is the suffering that the patient cries out with agony, and in 
a case under my observation suicide was attempted. Mental excite- 
ment, physical exertion, noises, and bright lights, aggravate the pain. 



TUMORS OF THE BRAIN. 297 

The special senses rarely escape. The sight is among the first to 
suffer derangement. Loss of sight may vary from slight dimness and 
narrowing of the visual field to complete blindness in both eyes. A 
tumor at the base of the brain which involves only one optic nerve 
will induce progressive blindness in the eye on the same side as the 
lesion. A tumor compressing the front of the chiasm will destroy the 
fibres going to the nasal half of each retina, and thus produce temporal 
hemianopsia of both eyes. If the optic tract, on one side, back of the 
chiasm, is the seat of a tumor, the fibres leading to the temporal half 
of the retina on the same side, and the nasal half of the retina on the 
opposite side, will be destroyed, thus inducing the condition known as 
homonymous hemianopsia. 

Cerebral tumors sometimes result in blindness simply from in- 
creased intra-cranial pressure. In this case the condition known as 
choked disk can be readily demonstrated by means of the ophthalmo- 
scope. Choked disk is always followed by atrophy of the optic papilla. 

Affections of smell and hearing are of much less frequent occur- 
rence. Jacobi 1 finds that in a total of five hundred and fifty-four 
cases of brain tumor, hearing, taste, and smell were only affected in 
sixty-seven, or twelve per cent. " In forty-six out of these sixty-seven 
cases the patients suffered from either tinnitus or deafness, the latter 
rarely complete. In twenty-six out of the forty-six, thus in more than 
half (fifty-six per cent.), the tumor was situated in the cerebellum. 
This fact tends to confirm, if need be, the recent anatomical demon- 
stration, which traces the central fibres of the acoustic nerve to the 
cerebellum." Tumors of the corpora quadrigemina also produce deaf- 
ness, probably on account of their proximity to the auditory tract in 
the tegmentum. 

Loss of the sense of smell is still more uncommon. Tumors situ- 
ated in the frontal lobes have frequently been found without any ab- 
normities of the sense of smell having been observed during the life 
of the patient. Tumors in this region, however, have been known to 
produce anosmia, usually accompanied by severe and continuous frontal 
headache. The headache in these cases is jDrobably due to the press- 
ure exerted upon the meninges. 

Disorders of sensibility in various parts of the body are common. 
These are either of the nature of hemi-anaesthesia, hyperesthesia, or 
numbness and tingling. 

Hemi-anaesthesia may or may not accompany hemiplegia. It is 
usually the result of a growth involving the posterior portion of the 
internal capsule, and, like hemiplegia, is gradual in its advancement. 
Pain, numbness, and tingling are most frequently produced by tumors 
situated in the central region of the hemisphere. 

Vertigo is a very general symptom, and may be of all degrees of 
1 "Hysteria and Brain Tumor," 1888, p. 119. " 



298 DISEASES OF THE BRAIN. 

intensity, sometimes preventing the patient standing, walking, or even 
sitting. It is often observed very early in the course of the disease, 
and is frequently accompanied by nausea or vomiting. 

The disorders of motility are shown either as paralysis, which 
may or may not be accompanied by contractures, or as mobile spasms, 
including convulsions, localized spasms, tremor, incoordination, and 
choreiform movements. Paralysis may occur either as hemiplegia, in- 
volving the leg, the arm, and the lower part of the face, or it may be 
more locally confined to the face, to an arm, or to a leg, or the face 
may be paralyzed on one side and the arm and leg on the other, or, 
more rarely, both arms or both legs may be affected. If it is of the 
hemiplegic variety, the tumor will be found to involve either the in- 
ternal capsule, the crus, or the pons on the side opposite to the para- 
lyzed members. Paralysis of the face and arm, or of the arm alone, 
or of the leg only, usually indicates that the tumor is situated in or 
just beneath that part of the cortex in which the motor centres for 
the face, arm, and leg are respectively situated. 

Crossed paralysis — that is, paralysis of one or more of the cranial 
nerves on one side and paralysis of the arm and leg on the other side — 
always indicates a lesion below the hemispheres either in the medulla, 
pons, or crus. A tumor so situated as to involve one or more of the 
cranial nerves, and at the same time implicate the motor tract before 
it decussates, will always produce crossed paralysis. 

Bilateral paralysis of both arms or of both legs can only occur un- 
der two conditions : either there are two tumors, one in each hemi- 
sphere, and both involving the same part of the motor tract in their 
respective hemispheres, or there is a single tumor so situated as to 
compress both motor tracts. In the first case the tumors are usually 
found in the hemispheres in the vicinity of the internal capsule. In 
the second case the tumor will be found lower down, either on the 
surface of the brain between the two cerebral peduncles, and thereby 
compressing both of them, or else in the mesial line of the pons. In 
whatever form the paralysis may appear, it is almost always of slow 
progress. This is an important factor in distinguishing brain tumors 
from cerebral haemorrhage. 

Contractures, muscular rigidity, accompanied by exaggerated re- 
flexes and by clonus, sometimes follow the paralysis or keep pace with 
it. When these symptoms are observed it indicates the gradual de- 
struction and descending degeneration of the motor tract. 

Tumors of various degrees, athetoid and choreic spasms, and in- 
coordinate and ataxic movements, are sometimes observed. The pres- 
ence of these different forms of mobile spasm is not a characteristic 
of brain tumor alone ; they are seen in several other affections, and 
depend, in my opinion, upon the irritation of nerve-cells either in the 
cortex, the thalamus, the striatum, or in the cell area of the pons. 



TUMORS OF THE BRAIN. 299 

Convulsions are other prominent symptoms, and they may be 
among the initial phenomena. It is not at all unusual for the first 
evidence of intra-cranial disturbance to be an epileptiform convul- 
sion, and similar paroxysms may occur at intervals for many years. 
They may be general, or, what is more common, limited to one 
side of the body, or they may be localized in either extremity or in 
the face. 

Ordinary epileptic convulsions are only of significance as an indi- 
cation of general cerebral irritation, but where the convulsive move- 
ments are limited to one extremity, or to a part of one extremity, the 
exact situation of the seat of irritation can be more concisely deter- 
mined. Thus, if the convulsion is limited to the hand or to the arm, 
the tumor can, with almost absolute certainty, be located in or just 
beneath that part of the cortex where the motor centres for the hand 
and arm are situated. This has been successfully attempted in a num- 
ber of instances, and the tumor has been removed. 

Sometimes consciousness is not lost, but there are various convulsive 
movements of the limbs, tonic or clonic in character. Occasionally 
these are confined to the muscles of the face or eyeball. 

Disturbances of equilibrium, manifested by tendency to advance, to 
go backward, or to turn round to the right or left, are sometimes present. 

With these symptoms there are generally others not so palpably 
connected with the morbid intra-cranial process. Thus there may be 
disorders of the stomach, bowels, and kidneys, and of the respiration 
and circulation, which add much to the discomfort of the patient. 

As to the intellectual faculties, it is not uncommon to find that 
they do not become involved to any considerable extent till a late pe- 
riod of the disease. Then the change is usually a gradually-advancing 
imbecility. 

Death takes place either by convulsions or coma, or a combination 
of both. The following cases, which I select from my note-book, are 
interesting in several relations: 

J. H., male, aged thirty-seven, came under my observation January 
15, 1856, at Fort Riley, in Kansas. A few months before he had re- 
ceived an injury of the left hip by being thrown from his horse, and 
was stunned for a few minutes. A few days afterward, as he was lying 
in bed, he suddenly became vertiginous, and at the same time had 
noises in his ears and some pain not very definitely located. He never 
had vertigo again, but the pain never left him night or day for several 
weeks. It then suddenly ceased, and did not recur till the morning of 
December 31st, when a sharp twinge was experienced in the front of 
the head, and he immediately saw every thing double. Ptosis and 
dilated pupil of the left eye soon supervened, and the arm of the right 
side became weaker. When I saw him the grasp of his hand was very 
feeble, and the ocular troubles very noticeable. The pain was almost 



300 DISEASES OF THE BRAIN. 

constantly present, and was of the most intense character. He said it 
seemed as if a red-hot iron were being thrust through his brain. 

He had come several miles to see me, and went home after I had 
given him a palliative medicine. A few days afterward a messenger 
came for me in great haste, with the information that the patient was 
dying, and requesting my attendance. On my arrival, I found that he 
had been dead several hours, having had repeated severe convulsions. 
On post-mortem examination, a tumor, spheroidal in shape, with an 
average diameter of an inch and a quarter, was found occupying the 
middle third of the inner surface of the left middle lobe, so as to press 
on the left crus and third nerve. 

The points of interest in this case are the sudden cessation of the 
pain and its recurrence simultaneously with the paralysis of the third 
nerve, the slight paralysis of the body, and the absence of convulsions 
till just before the fatal termination. The ptosis, diplopia, and dilata- 
tion of the pupil, doubtless occurred at the very instant that the tumor 
encroached on the crus. 

The history of the following case, which I saw in September, 1864. 
at the request of my friend Prof. Van Buren, I take from the report 
of Dr. F. N. Otis, 1 under whose immediate care the patient was : 

Miss E., aged twenty-six, was of healthy parentage, and, though 
of delicate organization, had enjoyed good health up to February, 1861, 
when she received a fall on the ice, striking violently upon her elbow. 
She was not conscious of receiving any other injury at the time. At 
3 A. m. of the following day she awoke with an intense pain in the 
top of her head, of a throbbing, lancinating character, which continued 
throughout the day. By night she obtained relief. No further effect 
from the fall was experienced until about two weeks subsequently, when 
she discovered a small, firm, circumscribed swelling on the crown of the 
head at the point where the pain had previously been felt. This swell- 
ing, which was painless, increased gradually, until, after a year, it had 
attained the size of half a lemon. Soon after the appearance of the 
tumor, Miss E. began to suffer with severe pain, confined chiefly to the 
vertex, of the same character as that experienced immediately after 
the fall. This pain would continue almost without cessation for two 
or three weeks, after which for a like period she would be quite free 
from it. 

She had also occasional attacks of numbness, preceded by great 
drowsiness, and a cold, creeping sensation, succeeded by total loss of 
the power of motion, sometimes confined to a single extremity, and at 
others involving the entire body. These attacks usually came on at 
night, or after rest in a recumbent position, and generally, though not 
invariably, were precursors of severe headache. They were always fol- 
lowed by great nervous prostration. At first rare, they increased in 
1 New York Medical Journal, vol. i., 1865, p. 26. 



TUMORS OF TEE BRAIN. 



301 



frequency as the tumor enlarged, so that by February, 18G3, she was 
seldom free from them for more than ten or twelve days, and the tumor 
had doubled in size within the year. She now began to be much an- 
noyed by tingling, crawling sensations in her face and through the head 
after any unusual exertion in writing, reading, or singing, but rode 
daily on horseback with apparent benefit. As time passed, she had fre- 
quent dizzy turns, with nausea, and sudden flashes like electric shocks 
passing over the entire body, lasting only for an instant, but leaving 
her much prostrated. The headache, which was always of the most 
agonizing description, came to be referred chiefly to the tumor, though 
often associated with pain through the temples and other parts of the 
head. The muscles of the neck sometimes became rigid, and the vision, 
as well as the sense of taste and smell, often became very imperfect 
and continued so for weeks. Sometimes the power of speech would 
be lost, but she always retained perfect consciousness. These attacks 
rarely lasted more than an hour or two. 

On the 23d of October, 1864, she was attacked with a peritoneal 
inflammation, from the effects of which she died on the ninth day there- 
after. Leaving out the details of the post-mortem examination of 
other parts of the body, we find that an incision was made across the 
vertex from ear to ear, and the skin dissected from the tumor, at the 
apex of which it was found to be firmly adherent. The calvarium was 

Fig. 20. 




then sawn in a line one inch above the orbital margin around to the 
occipital protuberance ; the hemispheres of the cerebrum were then 
sliced, and the whole raised at the same time. 



302 DISEASES OF THE BRAIN. 

On removing the two hemispheres, which were adherent above, a 
tumor one and a quarter inch in thickness and three inches in diame- 
ter, of a dull lemon-yellow color, a little softer than the cerebral sub- 
stance, and separated into two lateral halves, was seen springing from 
the central surface of the dura mater. This intra-cranial tumor had 
insinuated itself into the sulci between the convolutions, and the 
dura mater could be traced between it and the bones. The situation 
of the tumor, and the relation to the exterior growth, are shown in 
the accompanying cut (Fig. 20). 

The microscopical examination by Dr. Gouley gave indications that 
both formations were encephaloid in character. 

Similar cases to the foregoing have been reported by Mr. Paget, 1 
of London, and by the late Dr. Isaacs, 2 of this city. It will be noticed 
that, in the case just cited, there were neither convulsions, paralysis, 
anaesthesia, mental derangement, nor difficulties of speech. When I 
saw the young lady, not long before her death, there were no symptoms 
present from which it could have been inferred that a tumor occupied 
any part of the intra-cranial cavity. 

I. R., a general officer of volunteers during the late war, consulted 
me in the spring of 1870, through his brother, for what was thought to 
be softening of the brain. The patient was stout and well made, had 
no difficulty of speech, no derangement of sensibility, and no paralysis 
of any part of the body. His senses were remarkably acute. His 
memory, however, was almost entirely gone, he had forgotten the 
names of his children, did not even know what city he was in, and 
could not tell me where he had been just before coming to see me. 
Besides this, there was absolutely nothing. His strength was enor- 
mous, and his grip one that I shall not readily forget. 

His previous history was that he had served arduously through the 
war, and had, on being mustered out of service, resumed his business 
as a lumber-merchant. No syphilitic taint could be discovered. Six 
months before I saw him he had been suddenly seized with an epilep- 
tiform paroxysm which was followed by agonizing pain in the head. 
A second convulsion ensued in about a month afterward, the pain Con- 
tinuing to be of the utmost severity, and almost without intermission. 
There was a third attack, and then the pain ceased ; but the failure of 
memory began to be manifested from that moment, and had gradually 
been becoming more pronounced. 

I diagnosticated a tumor involving mainly the white substance of 
one of the hemispheres, situated probably in the posterior lobe, and 
not affecting the motor tract, or the course of any of the cranial nerves. 
My principal reasons for not regarding the lesion as softening were the 
absence of paralysis or even paresis, the integrity of all the special 

1 " Surgical Pathology," London, 1853, vol. ii., p. 221. 

2 "Transactions of the Medical Society of the State of New York," 1859. 



TUMORS OF THE BRAIN. 303 

senses, and the absolute perfection of articulation. At the same time 
I regarded the matter as extremely doubtful, and I cite the case here 
merely as one of interest in which the disease was probably a tumor. 
The patient died during the first week in January of the present year 
(1871), but I have received no details of any post-mortem examination. 

In May, 1870, I was requested by Dr. Hermann Knapp to meet 
him in consultation in the case of a gentleman suffering from a cere- 
bral tumor. The morbid growth apparently occupied the right ante- 
rior lobe of the brain, and involved also the temporal region of the 
skull on the same side. The sight of the right eye was destroyed, and 
that of the left so much impaired that only strong lights or shadows 
could be distinguished. The lymphatic glands of the neck were very 
much enlarged. 

The pain was most acute night and day, with scarcely an intermis- 
sion. The right arm was numb and paralytic, but there was no abso- 
lute paralysis anywhere except in the ocular muscles. The mind was 
intact, and there had never been a convulsion. 

Under the use of the iodide of potassium and the protiodide of mer- 
cury the swelling of the cranium diminished, the swollen lymphatic 
glands were reduced, and the pain almost entirely abolished. I saw 
him several times afterward, and, when I discontinued my visits, he 
was doing wonderfully well. Subsequently, however, there was a re- 
turn of the symptoms, and death ensued. 

There was no history of syphilis in this case. 

The following account of a case, in which there was a tumor of the 
cerebellum, I have from my friend Prof. Austin Flint, M. D. : 

"In June, 1842, I was present, by invitation of Dr. James P. "White, 
of Buffalo, at the autopsy in the case of W. R, aged about forty years. 
I noted at that time the following brief account of the history as stated 
by Dr. White, the attending physician: 

"The illness was dated from the preceding February (five months), 
but he had previously complained of pain in the head, and lassitude. 
In February he had had chills, which were at first attributed to malaria. 
Subsequently vomiting was a prominent symptom; it occurred in the 
morning immediately after rising from bed. Cephalalgia was a fre- 
quent, not a constant, symptom. He referred the pain especially to 
the occiput. In April he left Buffalo to visit friends in Rochester. He 
was prostrated by the journey, and, his condition now being alarming, 
he returned home. Notwithstanding the treatment adopted, he grad- 
ually failed, and died June 7th. 

" There had never been convulsions nor paralysis. 

" Post-mortem Examination. — The body was considerably emacv 
ated. There was slight opacity of the arachnoid, and in some situations 
a small quantity of serum was effused beneath this membrane. The 
effusion within the ventricles was somewhat greater than usual. With 



304 DISEASES OF THE BRAIN. 

these exceptions, there were no morbid appearances, except in the cere- 
bellum. Here was a tumor of the size of an English walnut. It was 
of fine consistence, and supposed to be tuberculous. There was no ap- 
pearance of inflammation or softening of the cerebral substance around 
the tumor, which was situated in the right lobe of the cerebellum. 

" It was ascertained in this case that the venereal appetite had been 
wanting for many months before death. I recollect that Dr. White 
informed me at the time that vertigo was a feature in this case, and 
that it induced unsteadiness in the voluntary movements. Dr. White 
has since informed me that his recollection is' now distinct as regards 
this point.'- 

Causes. — The causes of cerebral tumors are so intimately connected 
with their character that a classification becomes at once necessary. 
Following Jaccoud x in this respect, I shall divide them into four groups : 
the vascular, the parasitic, the diathetic or constitutional, and the acci- 
dental. Even with this division we shall find that our knowledge of 
their etiology is not extensive. 

Vascular tumors are aneurisms of the cerebral arteries. The term 
does not include the capillary aneurisms of Bouchard and Charcot, re- 
ferred to under the head of cerebral haemorrhage, but applies only to 
dilatations of the larger arteries. According to Gouguenheim, 2 they 
are more common between the ages of fifty and sixty than at other 
periods of life, though cases were met with under the age of puberty. 
Tables given by Durand s are to the same effect, as is likewise the ex- 
perience of Lebert, 4 Gull, 6 and others. This is what might be expected 
from the known proclivity of the arteries to disease after the age of 
fifty. 

Sex appears to exert but little influence, though aneurisms of the 
cerebral arteries seem to be somewhat more frequent with men than 
women. 

As exciting causes, blows on the head, falls, sudden and great physi- 
cal exertion, intense emotion, or mental labor, embolism, and concentric 
hypertrophy of the heart, are to be mentioned. 

Parasitic tumors are caused by the migration of the embryos of the 
cysticercus and echinococcus from other parts of the body. 

Diathetic tumors are either cancerous, tuberculous, or syphilitic in 
character. The first named are more common during the adult period 
of life than any other, though they are met with at all ages. Although 
women are more subject to some forms of cancerous tumors than men, 
yet in the brain they are far more common in the male sex. Of forty- 

1 Op. tit, p. 247. 

2 " Des tumeurs anevrysmales des arteres du cerveau." These de Paris, I860, p. 12. 

3 " Des anevrysmes du cerveau." These de Paris, 1868, p. 87. 

4 " Klinische Wocbenschrift," Berlin, Nos. 20 to 42, 1866. 

6 " Guy's. Hospital Reports," third series, vol. v. 1859, p. 281, ft seq. 



TUMORS OF THE BRAIN. 305 

eight cases studied by Lebert, cancer of the brain was primary in forty- 
five, that is, made its first appearance in this organ. 

Offle, 1 of twenty-five cases of cerebral cancer, found that in thirteen 
the disease was confined to the brain, while, on the other hand, contrary 
to the generally received opinion, Dr. Mackenzie Bacon a found but ten 
primary cases out of seventy-three. 

There is no doubt that cancer of the brain is sometimes the result of 
traumatic cause. 

Tuberculous tumors of the brain are generally met with in young 
children, though they do occur, as in the case related by Dr. Flint just 
cited, in adults. They are almost always secondary to similar products 
in the lungs. 

Syphilitic tumors are, of course, the result of the syphilitic infection 
of the system. 

Accidental tumors may be caused by injuries, as was probably the 
case in one of the instances cited. Jaccoud, however, expresses the 
opinion that such an apparent relation is purely fortuitous, and that 
all we know of their etiology is that they are more common after the 
age of forty than before that period. 

Diagnosis. — The diagnosis of cerebral tumors is sometimes almost 
self-evident, in others it is equally impossible. This difference is due, 
not only to the various situations they may occupy, but also to their 
diverse nature. 

The presence of severe pain in the head for a long time is of itself 
some indication of the existence of a tumor if it is unaccompanied by 
febrile excitement. Epileptiform convulsions, occurring after the age 
of forty, should excite suspicion that their cause is to be found in a mor- 
bid growth of some kind. The character of the convulsive seizures will 
aid us in forming an opinion of their etiology. When produced by a 
tumor they are generally unilateral, the loss of consciousness is not so 
complete, and there is rarely subsequent stupor. The diagnosis from 
epilepsy is rendered more evident by the fact that, in tumor, the con- 
vulsions are seldom accompanied by mental weakness, and never by 
periods of actual unconsciousness. From softening the distinction can 
be made without much difficulty in the majority of cases. The acute 
pain, the integrity of the mind, and the absence of general paresis, will 
usually suffice. But sometimes the discrimination cannot be made, for 
there are cases of tumors in which there is very little pain, in which the 
mind is involved, and in which the paralysis is not very strongly 
marked. 

The occurrence of very limited paralysis points to the existence of a 
tumor, rather than any other affection. A gentleman is now under in v 
ca re, who, several years ago, had a cerebral haemorrhage, from which lie 

1 British and Foreign Medico- Chirurgical Review, July, 1865, p. 223. 
? " On Primary Cancer of the Brain," London. 18fi5. 
21 



306 DISEASES OF THE BRAIN. 

was rendered hemiplegic. He regained to a great extent his mental 
and physical powers, but a few days ago suddenly had diplopia from 
paralysis of the external rectus muscle of the left eye, by which internal 
strabismus was produced. As yet there have been no other head-symp- 
toms except vertigo, with which he has suffered a great deal in the last 
two years, and which was excessive when the diplopia appeared. In 
other respects the health is good, and the mind gives no evidence of be- 
ing affected. The paralysis of the external rectus is on the same side 
with the general hemiplegia. 

In my opinion, though I express it, of course, without positiveness, 
there is an aneurismal tumor pressing upon the sixth nerve after its 
emergence from the medulla oblongata, and probably affecting the left 
internal carotid artery. If this view be correct, other symptoms will 
certainly arise ere long. These will probably consist in the more exten- 
sive implication of cranial nerves, and in the supervention of hemi- 
plegia. 1 

The diagnosis of the character of the tumor is of interest, and some- 
times of importance with a view to the prognosis. 

Aneurismal tumors are more common in persons of advanced age 
than in the young, they are more frequently accompanied by vertigo, 
and they are more generally indicated by paralysis of one or more of 
the cranial nerves. The mental symptoms are not often marked. 

Parasitical tumors usually first manifest themselves by the occur- 
rence of epileptiform convulsions, and the mental faculties do not long 
remain unaffected, for the reason that such products are more common- 
ly seated in the gray substance of the brain than in the white tissue or 
the ganglia at the base. As these latter generally escape, troubles of 
motility are rare. Diathetic tumors are more easily recognized than 
any others, for the reason that we have other evidence of the existence 
of constitutional infection in the great majority of cases. As regards 
cancer, however, this aid is not generally afforded, the affection being 
usually primary, and not producing the ordinary indications of the can- 
cerous cachexia. But, as in the case cited in full, and the others re- 
ferred to, the existence of an external tumor is some indication, in con- 
nection with head-symptoms, that there is a corresponding growth with- 
in the cranium. 

Tubercle may be suspected in cases presenting the symptoms of 
cerebral tumor, when there are indications of similar deposits in the 
lungs or other parts of the body, when the subject exhibits evidence of 
possessing the tuberculous diathesis, or when the history shows heredi- 
tary tendency 

In a patient presenting the symptoms of a tumor of the brain, its 
nature may safely be considered syphilitic if, in addition, his clinical 

1 This patient was found dead in the water-closet of his residence shortly after tha 
foregoing lines were written. There was no post-mortem examination. 



TUMORS OF THE BRAIN. 307 

history shows that he is tainted with syphilis, or has, at some former 
period, suffered from it. 

In regard to accidental tumors or those of various anatomical char- 
acteristics, there is not much to be said of their diagnosis. There are 
no means by which one species can be distinguished from another, and 
no positive indications which can enable us to discriminate them from 
other tumors, except by the way of exclusion. 

Prognosis. — Cerebral tumors almost uniformly lead to a fatal result, 
except they be syphilitic in character. In these latter there is a very 
considerable prospect of recovery if the proper medical treatment be 
adopted ; and aneurismal tumors of the brain are occasionally sponta- 
neously cured, and are perhaps sometimes amenable to treatment. 

Morbid Anatomy and Pathology. — Vascular Tumors. — The most 
common seat of cerebral aneurisms is the basilar artery, and they are 
larger here than when any other vessel is affected. Gouguenheim 1 
gives the following table, based upon sixty-eight cases : 

Basilar 17 

Middle cerebral 14 

Internal carotids 12 

Anterior cerebral 8 

Posterior communicating 5 

Cerebellar 4 

Anterior communicating 2 

Posterior cerebral 3 

Middle meningeal 2 

Arterio-venous 2 

Cerebral aneurisms do not differ in any essential particular from 
similar formations in other parts of the body. They are, however, 
smaller, rarely being as large as a walnut, and generally ranging in size 
from that of a cherry-stone to that of an almond. 

Lebert ascertained that they were more frequently met with in the 
arteries of the left side of the brain than in those of the right. Gou- 
guenheim confirms this observation. Thus of forty-one cases in which 
the side was determined, twenty-seven were on the left, and fourteen 
on the right. This difference is doubtless, in part at least, due to the 
fact that one of the causes of cerebral aneurisms, embolus, is more com- 
mon on the left side than on the right, and in part to the circumstance 
that, the left common carotid arising directly from the arch of the aorta, 
the blood of that side has a greater degree of tension than the blood of 
the right side, and hence presses on the arterial walls with more force. 

In a very interesting paper, Prof. W. R. Smith 2 calls attention to 

1 Op. cit., p. 21. 

2 " Cerebral Aneurism : Reports of the Dublin Pathological Society." Dublin (Quar- 
terly Journal of Medical Science, November, 1870, p. 443. 



308 



DISEASES OF TIIE BRAIN. 



the fact that aneurisms of the encephalic arteries may be produced by 
embolism. The following figure, which I take from his memoir, gives 
an excellent illustration of such an aneurism in the left middle cerebral 
arterv : 

Fig. 21. 




In regard to the post-mortem examination of the patient, from whom 
the preparation was taken, Prof. Smith says: 

" Upon tracing the left middle cerebral artery into the fissure of 
Sylvius, it was found to be obstructed (just where it branches iuto twigs 
surrounding the island of Reil) by a plug of fibrine of a yellowish color 
and oblong form, fully a quarter of an inch in length and about the 
eighth of an inch in breadth. At the seat of obstruction the vessel 
was dilated into an oblong tumor half an inch in length and a quarter 
of an inch broad, the space intervening between the original plug and 
the arterial tunics being occupied by coagulated blood." 

The theory sustained by Prof. Smith was, as he freely states, first 
proposed by Dr. Senhouse Kirkes * in the paper to which I have already 
referred under the head of embolism. 

The idea was formerly very generally entertained, that cerebral 
aneurisms were always true, that is, caused by the uniform dilatation 
of all the coats of the artery. Hodgson 2 sustained this view on the 
ground that the tunics of the encephalic arteries were of such extreme 
tenuity that they readily dilated, and Albers, 3 Crisp, 4 Gull, 6 and others, 
held similar opinions, but the recognition of the fact that the arteries 
of the brain are peculiarly subject to disease in persons advanced in 
age, and the researches of Lebert, Virchow, and Kdlliker, go to show 
that such a view is erroneous. Three other kinds are known to exist: 
the mixed external, in which the interior and middle coats are ruptured 
and the sac is formed by the external coat; the dissecting, in which 



1 " Medico-Chirurgical Transactions," vol. xxxv., p. 852. 

2 "A Treatise on the Diseases of Arteries and Veins," London, 1815. 

3 "Memoire sur les anevrysmes du cerveau et ses meninges," Bonn, 1836. 

4 "A Treatise on the Structure, Diseases, and Injuries of the Blood-vessels, 
1847. 

5 " Guy's Hospital Reports," 1857. 



London 



TUMORS OF THE BRAIN. 309 

the internal tunic is ruptured and the blood is to a certain extent forced 
between the layers of the middle tunic ; and the arterio-venous. This 
latter is seated in the cavernous sinus, and is produced by the rupture 
of a small carotid aneurism, or it is the result of wound or injury. 

Aneurismal tumors may cause death either by the pressure which 
they exert on important parts of the brain or by the giving way of the 
sac and the consequent extravasation of blood, producing pressure and 
disorganization. 

The rupture of an aneurismal tumor of course leads to the sudden 
development of a new set of symptoms, varying in character according 
to the situation of the disease and the course which the extravasated 
blood has taken. The extravasation may occur between the membranes, 
or into the substance of the brain, or into the ventricles, and is generally 
followed by sudden death. Occasionally, however, the patient survives 
to undergo a second rupture, or to die from secondary alterations of the 
cerebral tissue. Lebert has reported a case of aneurism of the basilar 
artery, in which there was a spontaneous cure; and another of the mid- 
dle cerebral artery is cited by Durand * on the authority of Bourneville 
and Fremy. The process in such cases is similar to that which occurs 
in like cases in the extra-cranial arteries; the blood in the aneurismal 
sac becomes solidified, the arterial canal at this point is obliterated, and 
the circulation is carried on by the collateral vessels. 

Parasitic tumors are of two kinds, those produced by the cysticer- 
cus and those caused by the echinococcus or hydatids. The former are 
small, scarcely ever being larger than a small bean. They are rarely 
encysted, as in other parts of the body, but are in close apposition with 
the brain-substance. They are generally met with in numbers ranging 
from ten to twenty. Cruveilhier 2 reports a case in which there were 
over one hundred. 

They are found in all parts of the cerebrum and cerebellum; fifty of 
those discovered by Cruveilhier, in the case just cited, were in the cere- 
bellum. Generally they are near the surface of the brain — often in the 
pia mater, in which situation they press upon the gray matter, and 
often in this latter substance. When situated in the ventricles, there 
is less impediment to the growth of the parasite, and hence it may be- 
come developed into a more or less perfect tape-worm. 

Cobbold 3 states that there are about one hundred cases on record of 
cysticerci being found in the brain after death. Of these, Griesinger 4 
reports between fifty and sixty. 

Echinococci, or hydatids, though much larger than the foregoing- 

1 Op. tit., p. 14. 

s " Anatomie pathologique generale," tome ii., p. 83, Paris, 1852. 

3 " Entozoa : An Introduction to the Study of Helminthology, with Reference more 
particularly to the Internal Parasites of Man," London, 1864. 

4 " Cysticerken und ihre Diagnose," " Archiv der Heilkunde," 1862. 



310 DISEASES OF THE BRAIN. 

described parasites, are less numerous. Generally there is only one, 
and rarely are there two cysts. Each cyst may contain a single hy- 
datid, as is usually the case, or there may be more in different stages of 
growth. In size, the cysts vary from that of a marble to that of an 
orange, and consist of a vascular membrane inclosing the parasite. 

Of one hundred and thirty-three cases occurring in the human sub- 
ject and analyzed by Cobbold, sixteen were situated in the brain. All 
were of course fatal. 

Both of these species of parasitical tumors may be primary, or they 
may be accompanied by similar growths in other parts of the body. 

Diathetic tumors are either cancerous, tuberculous, or syphilitic. 

Cancer may affect any part of the brain, though it more generally 
attacks the hemispheres, the cerebellum, the optic thalami, the corpus 
striatum, or the pons Varolii. It may begin in the bones of the crani- 
um, in the membranes, or in the brain itself. A common seat is the 
orbit. According to Dr. Mackenzie Bacon, 1 of seventy -three cases of 
brain-tumors occurring in the London hospitals during the period from 
1854 to 1863, ten were cancerous. Ladame, 2 of three hundred and 
thirty-nine cases of cerebral tumors, collected from various sources, 
found that sixty-seven were cancerous. 

The dimensions of cancerous tumors are very variable. Generally 
they do not much exceed the size of an English walnut, though they 
may be twice as large. 

Either variety of cancer, encephaloid, scirrhous, or colloid, may have 
its seat in the brain. Primitive cancer is usually single; secondary, 
multiple. In a case reported by Dr. Webber, 3 of Boston, in which 
there was a preexisting cancerous tumor of the vagina, the brain was 
found to contain several deposits of cancerous growths — one quite 
large, situated in the left hemisphere, and two in the cerebellum. 

Ogle 4 has shown that the brain-substance surrounding the cancer- 
ous growth undergoes softening. Frequently it is not changed at all. 

The tumor itself does not often undergo softening, but a kind of 
fatty degeneration and atrophy occur, and the tissue becomes hard and 
compact, with no traces of blood-vessels remaining. 

Tubercular tumors may be either single or multiple. In the former 
case, they are often as large as a cherry ; in the latter, they may be as 
small as a grain of wheat. Very large tubercular tumors result from 
the fusion of two or more smaller ones. They are generally seated in 
the hemispheres or cerebellum, though the other parts of the encepha- 
lon are not exempt. They are the most frequently met with of all the 
forms of cerebral tumors. 

1 Op. cit. 

8 " Symptomatologie und Diagnostik der Hirngeschwtilste,' 
8 Journal of Psychological Medicine, vol. iv., 1870, p. 569. 
* Journal of Mental Science, 1864, p. 229. 



TUMORS OF THE BRAIN. 311 

/Syphilitic tumors or gummata are in general seated in the mem- 
branes, or in these and the gray matter at the base of the brain. They 
are very rarely entirely confined to the substance of the brain, and are 
never encysted. They are, therefore, not distinctly circumscribed, but the 
elements of which they are composed are infiltrated into the surround- 
ing brain-tissue. In size they vary, rarely being as large as a walnut. 
Histologically they consist of nuclei and cells. The former contain 
nucleoli and occupy the periphery of the tumor, while the cells are 
found mainly in the centre. Syphilitic tumors are ordinarily accompa- 
nied by like growths in other parts of the body, especially the lungs 
and liver. 

Accidental Tumors. — Under this head are included all formations 
not diathetic or vascular. Among them are the fibro-plastic tumors, 
which may attain to the size of an orange, and which are generally 
growths from the dura mater at the external part of the base of the 
cranium. They are composed of fusiform cells, nuclei, and blood-ves- 
sels. They are of variable consistence, sometimes being almost fluid, 
and at others gelatinif orm in character. 

Under the name of glioma, Virchow described a cerebral growth 
due to an abnormal development of the neuroglia or connective tissue 
of the brain. They are more generally found in the posterior cerebral 
lobes, and may attain to the size of an orange. Usually there is but 
one. There are two kinds of these tumors, one soft, being about the 
consistence of the brain-substance, the other much harder. They con- 
sist of cells and nuclei, but never contain any of the nervous elements. 
Gholesteatomata, sometimes called pearly tumors, may arise from the 
cranial bones, from the membranes, or from the brain itself. They 
rarely attain to the size of a walnut, and are generally very much 
smaller. Histologically they consist of a limiting membrane of ex- 
treme tenuity, the contents of which are disposed in concentric layers. 
These strata are epidermic cells which have undergone degeneration. 
There are no vessels either in the envelope or the contents, which, in 
addition to the elements just mentioned, consist of cholesterine and 
stearine. 

Virchow ' has applied the term psammomata to tumors composed of 
cerebral sand. The most common seat of these growths is the parietal 
dura mater at its anterior part. They are of firm consistence and are 
rarely larger than a cherry ; microscopically they are seen to consist of 
isolated grains of carbonate of lime, surrounded by concentric layers 
of epithelium held together by connective tissue. Similar tumors are 
met with in the choroid plexus of the fourth verticle. 

In addition to these there are osseous tumors (exostoses), growing 
from the cranial bones, and which may or may not be syphilitic, lipo- 
matous, enchondromatous, mucous, melanotic, and several other species 
1 " Pathologie de? tumeurs," tome ii. Paris, 1869, p. 105. 



312 DISEASES OF THE BHAIN. 

y>i tumors, which are treated of fully in the special monographs on the 
subject, but which need not detain us in the present connection. 1 

Two bodies cannot occupy the same space at the same time. In a 
state of health, the brain so nearly fills the cranial cavity that there is 
barely room for those variations in the amount of blood and ventricu- 
lar fluid which occur within the normal limits. The growth of a tumor, 
therefore, is at the expense of the brain. As the former increases in 
size, the latter diminishes, and hence some of the .symptoms resulting 
from tumors are similar to those which follow atrophy or sclerosis. 
Besides, we have other consequent effects, such as oedema, congestion, 
ansemia, haemorrhage, inflammation, or softening. 

When cerebral tumors press upon the cranial nerves they produce 
fatty degeneration and atrophy. This effect is manifested by altera- 
tions of sensibility or of motility in the parts supplied by these nerves, 
Jn the eyes, however, in addition, the changes can be seen with the 
ophthalmoscope. They consist in the main of atrophy of the optic, 
disk, disappearance of the vessels, congestion of the retina, or haemor- 
rhage, or serous infiltration with detachment. As Jaccoud remarks, 
easily appreciated by the ophthalmoscope, these lesions have a real im- 
portance in clinical diagnosis. 

As to the relation between the symptoms and the seat of the lesion, 
the principles enunciated under the head of cerebral haemorrhage are 
applicable to cerebral tumors. 

Treatment. — An English surgeon, Mr. Coe, 2 reports the case of a 
woman, aged fifty -five, who had enjoyed good health till on one occa- 
sion she had an altercation with her husband, during which she was ex- 
cited to very great anger, and in the course of which she received sev- 
eral severe blows on the head. About the same time she made severe 
efforts to lift some heavy burdens. A few minutes afterward she com- 
plained to a neighbor of a violent noise in her head — a sensation which 
she had never experienced before. She compared the sound to that 
made by the working of a fire-engine, and said that it was heard more 
distinctly in the left than the right ear. It was accompanied by a con- 
tinuous roar similar to that of distant thunder, and this was apparently 
situated at the superior and posterior angle of the right parietal bone. 

From the beginning of these symptoms she had not been able to lie 
down, but was obliged to sleep in a sitting posture. Her dreams be- 
came exceedingly frightful, and she often awoke starting and terrified. 

On examination nothing abnormal could be detected in the region 
of the heart or great vessels, but in the neck a strong aneurismal bruit, 

1 For a very full and complete essay on the subject of Cerebral Tumors, the reader 
is referred to Dr. J. W. Ogle's cases illustrating the " Formation of Morbid Growths, 
Deposits. Tumors, Cysts, etc., in Connection with the Brain and Spinal Cord and thcii 
Investing Membranes," British and Foreign Medico- Chirurgical Review, 1864-'65. 

2 Cited by Gouguenheim, from Association Medical Journal, November, 1855. 



TUMORS OF TIIE BRAIN. 313 

synchronous with the pulse, was discovered. It was heard distinctly 
over the who*e surface of the head, but was louder over the left tem- 
poral bone. On compressing the right common carotid artery, no effect 
was produced in the murmur, but pressure on the left common carotid 
caused it to cease at once. There was slight strabismus of the left eye, 
and vision was not so perfect in this eye as in the right. The hearing 
was not affected, but the noise in the head was so great that it over- 
powered the sound of the carriages in the street. 

Mr. Coe diagnosticated an aneurism of the left internal carotid 
artery at its entrance into the cavernous sinus immediately after its 
emergence from the petrous portion of the temporal bone. 

On the 11th of December, 1851, Mr. Coe ligated the left common 
carotid artery. The bruit instantly ceased, but a soft and almost con- 
tinuous murmur succeeded, and could be distinctly heard on applying 
the stethoscope to a point just above the left ear. 

The patient kept the horizontal position for five hours after the 
operation. On the 13th there was no noise in the head, even when she 
concentrated her attention in the effort to hear it. From this time on- 
ward she continued to improve, and the bruit was never heard again. 

The probability of this case being one of cerebral aneurism is of 
course very great, and the result leads us to believe that such tumors 
are not entirely beyond the reach of remedial measures. So far, how- 
ever, as other tumors of the brain are concerned, there is no treatment 
calculated to cure the patient, unless a syphilitic taint can be ascer- 
tained to exist. It is well, however, even when there are no positive 
indications of the presence of such a diathesis, to act upon the pre- 
sumption that it does exist, and to administer mercury in some form 
with the iodide of potassium. By adopting this principle, I have sev- 
eral times succeeded in curing patients who exhibited the most positive 
indications of suffering from tumor of the brain. One very remarkable 
case was that of a gentleman who consulted me several months since 
for ptosis, double vision, dilatation of the pupil, vertigo, and cephalalgia. 
The opinion was expressed by other physicians that there was a cere- 
bral tumor, and I entirely accorded with the view. The gentleman had 
no recollection of ever having had a chancre of any kind, but I never- 
theless administered the bichloride of mercury and iodide of potassium, 
according to the following formula: I£. Hyd. bichlor. (corros.) gr. ij, 
potass, iodidi 3 v, aquge § iv. M. ft. sol. Dose, teaspoonful three times 
a day. At the next visit of the patient he remembered that when 
in China, several years previously, he had contracted a chancre for 
which he was treated. I continued the treatment, conjoining it with 
the use of electricity to the eye so as to act upon the paralyzed 
muscles, and had the satisfaction to see a gradual but steady improve- 
ment take place, till eventually in the course of a few weeks the cure 
was complete. 



314 DISEASES OF THE BRAIN. 

Another case was that of a lady who consulted me in July, 1870, 
for agonizing pain in the head, vertigo, and paralysis of the third nerve 
of the left side, the latter producing ptosis, external strabismus, and 
consequent diplopia. I could discover no evidence of syphilis, but 1 
nevertheless administered the bichloride of mercury and the iodide of 
potassium, as in the foregoing case. The induced or faradaic current 
was applied to the eye, and the patient soon began to mend. The 
headache disappeared first, then the vertigo, and eventually the paraly- 
sis. Subsequently I ascertained from the lady's husband that it was 
barely possible he might have infected his wife. I have no doubt what- 
ever that he did. 

The medication recommended can do no harm. There is, therefore, 
no reason why the patient should not have the chance of being benefited 
by it. 

The prescription mentioned is a very eligible form for administering 
both the mercury and iodide of potassium. Salivation is never caused 
by it, and the stomach generally tolerates it well. Of course the pro- 
portions of the ingredients can be altered, as may seem best in individ- 
ual cases. 

The induced galvanic current is beneficial in restoring contractility 
to the paralyzed muscles. When applied to the eye the lids should be 
closed, one electrode, a wet sponge, is placed on them, the other is held 
in the hand or placed on the nape of the neck, and a current not so 
strong as to cause any considerable pain is then allowed to pass through 
the intervening tissues. For the relief of the pain attendant on cere- 
bral tumors, morphia may be administered hypodermically, or, what I 
have found advantageous in several cases, the extract of Indian hemp, 
as recommended by Reynolds, may be used. 

Counter-irritation, as produced by the actual cautery or other less 
powerful means, can do no possible good, and only adds to the discom- 
fort of the patient. 

Where a diagnosis of a cortical or subcortical tumor can be made, 
recovery may be hoped for in a fair proportion of cases if operative 
measures are resorted to promptly. The death-rate, as a direct result 
of the operation, is small when the serious nature of the operation is 
taken into consideration. In sixty- three cases of cerebral growths of 
various kinds, tabulated by Park, 1 only five deaths could be laid to the 
operation itself. In regard to the ultimate recovery from the epilepsy 
in cases of cortical and subcortical tumors, it can only be said that the 
prognosis is fairly good. Several cases have been reported as cured, 
when time has shown that the report was not justified by the subse- 
quent return of the convulsions. Nevertheless, the statistics show that 
in fully fifty per centum of the cases operated upon either great im- 
provement or complete recovery results. 

1 "Surgery of the Brain." Trans. Cong. Am. Phys. and Surg., vol. i., 1888. 



ATHETOSIS. 315 

CHAPTER XV. 

ATHETOSIS. 

Under the name of athetosis ('A0€tos, withovt fixed position) I 
propose to describe an affection which, so far as I know, had not, pre- 
vious to the publication of the first edition of this work in 1871, at- 
tracted the attention of medical writers, and of which several cases 
have come to my knowledge. It is mainly characterized by an inability 
to retain the fingers and toes in any position in which they may be 
placed, and by their continual motion. From these phenomena, I have 
applied the term athetosis to the disease, having as yet had no oppor- 
tunity of ascertaining by post-mortem examination the nature of the 
lesion to which the symptoms are due. 

Since then the disease has been admitted to be well founded by 
several eminent pathologists, among them Dr. Clifford Allbutt, 1 Dr. 
Gairdner, 2 Dr. Clay Shaw, 3 Dr. C. C. Ritchie, 4 Dr. Eulenburg, 5 and 
Dr. Sydney Ringer. 6 It has also been studied by MM. Charcot, 7 
Gairdner, 8 Oulmont, 9 Landouzy, 10 Grasset, 11 and Brousse, 12 in France, 
Bernhardt, 13 in Germany, and others in Europe and this country. 

These symptoms will be evident from the following histories : 

J. P. R., aged thirty-three, a native of Holland, consulted me Sep- 
tember 13, 1869. His occupation was bookbinding, and he had the 
reputation, previous to his present illness, of being a first-class work- 
man. He was of intemperate habits. In 1860 he had an epileptic 
paroxysm, and, since that time to the date of his first visit to me, had 
had a fit about once in every six weeks. In 1865 he had an attack of 
delirium tremens, and for six weeks thereafter was unconscious, being 

1 "Cases of Athetosis," Medical Times and Gazette, January 27, 1872. 

2 Cited by Dr. Clay Shaw, who gives no reference, and I have been unable to find the 
original. 

3 " On Athetosis ; or, Imbecility with Ataxia," " St. Bartholomew's Hospital Reports," 
vol. ix., 1873, p. 130. 

4 "Note on a Case of Athetosis," Medical Times and Gazette, March 23, 1872. 

5 "Athetosis," Ziemssen's "Handbuch der speciellen Pathologie und Therapie," zwolf- 
terBand, "Krankheiten des Nervensystems," II., zweite Halfte, 1875, p. 389. 

6 " Notes on a Case of Athetosis, preceded by Hemiplegia and Haemianaesthesia, and 
accompanied by Unilateral Sweating," Practitioner, August, 1877. Also, "Notes of a 
Post-mortem Examination in a Case of Athetosis," Practitioner, September, 1879. 

7 "De PAthetose," Legons sur les maladies du systeme nervcux. Paris, 1877. 

8 "A Case of Hammond's Athetosis," etc., Lancet, June 9, 1877. 

9 "Etudes cliniques sur l'athetose," These de Paris, 1878. 

10 "Note sur un cas d'athetose," etc., Progres Medical, 1878, Nos. 5 and 6. 

11 "Quatre nouveaux cas d'athetose," etc., Montpellier, 1879. 

12 Montpellier Medical, t. xxxiv., Aout-Septembre, 1877. 
a Virchow's Archiv. B. lxvii., H. i. 



316 DISEASES OF THE BRAIN. 

more or less delirious during the whole period. Soon after recov- 
ering his intelligence he noticed a slight sensation of numbness in 
the whole of the right upper extremity, and in the toes of the same 
side. At the same time severe pain appeared in these parts, and 
complex involuntary movements ensued in the fingers and toes of the 
same side. 

At first the movements of the fingers were to some extent under 
the control of his will, especially when this was strongly exerted, and 
assisted by his eyesight, and he could, by placing his hand behind 
him, restrain them to a still greater degree. He soon, however, found 
that his labor was very much impeded, and he had gradually been 
reduced, from time to time, to work requiring less care than the finish- 
ing, at which he had been very expert. 

The right forearm, from the continual action of the muscles, was 
much larger than the other ; and the muscles were hard and developed, 
like those of a gymnast. 

When told to close his hand, he held it out at arm's length, clasped 
the wrist with the other hand, and then, exerting all his power, suc- 
ceeded, after at least half a minute, in flexing the fingers, but instanta- 
neously they opened again and resumed their movements. 

I treated him with galvanism, primary and induced, for four months, 
without notable result. His fits were, however, arrested with bromide 
of potassium. 

His memory began to be impaired soon after his attack of delirium 
tremens, and his intellect was manifestly weakened when I first saw him. 

January 17, 1871, at my suggestion, he attended the New York 
State Hospital for Diseases of the Nervous System, when the following 
points, which I cite from the report of Dr. Cross, the Resident Physi- 
cian, were noted : 

The head is symmetrical, but is peculiar in shape — the posterior 
portion rising to a much higher point than the anterior, while the lat- 
ter slopes downward and forward, giving the cranium the form of that 
of a Flathead Indian. The special senses are normal. The intellect is 
somewhat impaired, and his ideas are not so vivid at one time as at 
another. His memory is much enfeebled. There is slight tremor of 
both upper extremities, but there is no paralysis of any part of his body. 
There are, however, involuntary grotesque muscular movements of the 
fingers and toes of the right side, and these are not those of simple 
flexion and extension, but of more complicated form. They occur not 
only when he is awake, but also when he is asleep, and are only re- 
strained by certain positions, and by extraordinary efforts of the will. 
Thus, those of the fingers are arrested when the wrist is firmly grasped 
by a strong hand, or when it is less forcibly held in a vertical position. 
But if the arm be extended horizontally, the fingers at once begin their 
movements. During their continuance the arm is hard and rigid, and 



ATHETOSIS. 



317 



the calf of the leg is also in the same state of tonic spasm while the 
toes are in motion. The movements are somewhat paroxysmal, being 
worse at times than at others. During the remissions, the power of the 
will over the muscles is more effective than when the paroxysms are at 
their height. 

Sensibility to touch, pain, tickling, and temperature is normal in 
all other parts of the body. There is slight tremulousness of the 
tongue, but no difficulty of articulation. There are no oscillatory 
movements of the eyeballs (nystagmus). 

The involuntary contractions of the fingers and toes do not take 
place quickly, but slowly, apparently as if with deliberation, and with 
gieat force. The numbness and pain in the arm, hand, leg, and foot 
have increased in proportion to the increase in the contractions. 

The toes are not involved to the same degree as the fingers. Posi- 
tion does not, however, afford the same relief to them as to the fingers, 
and the spasms are more tonic in character. The muscular develop- 
ment is greater in the right arm and leg, from the almost continuous 
muscular action. The toes are kept restrained to some extent by the 
boot, but as soon as it is removed they become flexed, and take on their 
peculiar movements. 

When, by a strong effort of the will, he succeeds for an instant in 
arresting the movements in the hand, the little finger at once be- 
comes strongly abducted, the third finger participates to some ex- 
tent, the second finger is slightly flexed, the index-finger is extended, 
and the thumb is extended to its very utmost. These are the posi- 

Fig. 22. 




tions in all cases in which he succeeds in quieting the actions, and 
they are well shown in the accompanying woodcut (Fig. 22), taken 
from a photograph. 

On account of the severe pain in the whole arm, caused by the 
spasms of the muscles, the patient is at times unable to go to sleep 



318 DISEASES OF THE BRAIN. 

until quite exhausted. On awaking, however, after a few hours > re- 
pose, although the actions have continued during his sleep, they are 
not so severe as at any other time through the day or night. This 
state of comparative repose lasts for about half an hour. 

His habits are bad. He boasts that he has often drunk as many as 
sixty glasses of gin in a day, and it is therefore doubtful whether the 
tremulousness observed in the tongue and the muscles generally is the 
effect of the disease, or of drink, or of both combined. I have never, 
however, seen him drunk, or even under the influence of liquor. His 
mental faculties are decidedly more obtuse than when he first came 
under my observation. 

Under the use of the primary galvanic current to his brain, spinal 
cord, and affected muscles, and the internal use of chloride of barium, 
he improved for a short time, but I have no hope of any permanent 
result being obtained. His epileptic paroxysms are kept down with 
bromide of potassium. 

In May, 1873, on the occasion of reading a paper on athetosis be- 
fore the Medical Library and Journal Association, I brought this 
patient to the meeting ; and at the meeting of the American Neuro- 
logical Association in this city, in June last, I again showed him as 
the case on which I had based my description of the disease. At 
that time he was in about the same condition as when he first came 
under my notice. 1 

Since then the patient has repeatedly come under my notice, and 
thus far exhibits no material change in his condition, except as regards 
his mental power. This is decidedly weakened. The epileptic convul- 
sions still continue, though they are not so frequent as they once were, 
and are readily controlled by the bromide of potassium, or sodium, 
when he can be induced to take it with any approach to constancy. 
The muscles of the affected arm and hand are greatly hypertrophied, 
and he occasionally suffers from pains in both right extremities. He 
informs me that he has entirely stopped the use of alcoholic liquors. 

The second case occurred in the practice of Dr. J. C. Hubbard, of 
Ashtabula, Ohio, who forwarded to me the following excellent report, 
lated January 11, 1870, and two photographs — one full-length on a 
small scale, and another, from which the woodcut, Fig. 22, has been 
engraved : 

" H. S., aged thirty-nine years, a farmer by occupation, married. 
His father and paternal grandfather were free drinkers of ardent 
spirits. His only brother died of phthisis pulmonalis, and I think he 
inherits a tubercular tendency from his mother. The patient is short, 
muscular, is well made, and has always had good health till about eight 
years ago, when he had several attacks of headache, followed by ver- 
tigo and loss of power to maintain the upright posture, or to sit in a 

1 " Transactions of the American Neurological Association," toI. L, 1875, p. IV. 



ATHETOSIS. 319 

chair. After falling, he lost consciousness for a few moments. He 
had three of these attacks in two months. 

" Three years after the last one — being five years and a half ago — 
while at work on a hot day in the open air, he lost consciousness and 
fell to the ground. This attack was more severe than the preceding 
ones, and he was confined to his bed three days. The headache was 
very severe, and continued a week after he left his bed. Aphasia and 
the incoordination now affecting his right forearm and right leg were 
the sequence of this stroke. His powers of speech were gradually re- 
established in the course of six weeks, but the impediment to normal 
voluntary muscular motion has remained to this day. 

"In June last (1869) he applied to me for relief from cephalalgia, 
pain in the right side of the chest, cough, and dyspnoea. He com- 
plained also of vertigo, and of flashes of light before his eyes. His 
memory and judgment were slightly impaired, and he was gloomy and 
irritable. 

" His utterance of most words was perfect, but he stammered over 
at least one word in each sentence. It required a good deal of effort 
for him to connect his ideas and his sentences. He stumbled at mono- 
syllabic words, such as then, to, at, and, and other conjunctions, but 
in a moment, after considerable effort, he could speak these words and 
conjoin his sentences correctly. 

" On examining his right foot, I found that he had lost the normal 
antagonizing force between the flexors and extensors of the toes. The 
toes were ordinarily in a state of flexion, so as to present their ends to 
the floor. He could restore the balance in muscular action by a strong 
effort of the will, pressing at the same time the sole hard upon the 
ground, and drawing the foot backward a little. Soon, however, the 
extensors would be wearied by their extra work, and the toes would 
resume -their abnormal position. The foot is slightly inverted at every 
step, and it is not exactly guided by the will. His gait is awkward — 
the foot being set down with a kind of pawing motion, as in talipes 
varus. 

"A similar incoordination is observable in the right hand and 
fingers. He cannot flex his fingers without the aid of the opposite 
hand, but when it is closed the grasp is as strong as ever. By an in- 
tense action of the will he can keep his fist closed for a few moments, 
till the apparently tired flexors give way. The little and ring fingers 
are but partially extended, and are strongly abducted. The abductor 
minimi digiti and the flexor brevis minimi digiti are hypertrophied, 
firm, hard, and in a state of contraction most of the time, and the 
affected hand measures three-fourths of an inch more around the palm 
than its fellow. Tactile sensibility is as perfect in the affected limbs 
as in the others. His muscular powers are good, and he thinks he can 
walk twenty-five miles without injurious fatigue. The temperature of 



320 DISEASES OF THE BRAIN. 

the affected limbs is slightly lower than that of the opposite ones. Has 
slight headache frequently, generally at evening ; sleep relieves it. 
He sleeps well when undisturbed by pains in his limbs. Tongue clean 
and tremulous. Has slow-moving; pains, from the hand and foot up 
to the body ; they often last half a day, and are worse at night. Has 
no pain, tenderness, or feeling of weakness in any part of the spine. 

" He had no systematic treatment till last June. The chest-symp- 
toms referred to were owing to subacute bronchitis. A seton was in- 
serted between the shoulders, and iodide of potassium was adminis- 
tered for ten days. His lungs being then better, phosphoric acid, 
cerium, cannabis indica, sulphate of quinine, and sulphate of iron were 
given till the first of December following. He then felt so much 
better that he discontinued the medicines. The seton continued to 
discharge till the date of this communication (January 11, 1870), and 
he presents at this time a very marked improvement. His headache is 
not severe, he has less pain in his limbs, and he speaks without hesita- 
tion. By a strong effort of the will he can close his hand without 
assistance. He came five miles on foot, in a driving snow-storm, to 
see me to-day." 

The accompanying woodcut (Fig. 23) is from one of Dr. Hub- 
bard's photographs. The resemblance to the condition shown in Fig. 
22 is very striking, and the histories of the two cases are so nearly 

Fig. 23. 




identical, in regard to all essential points, as to leave no doubt that 
they describe instances of the same disease. Dr. Hubbard's case was, 
probably, when he wrote the history, in a more advanced state than is 
mine at the present time. The distortion of the hand is certainly 
greater. In the other photograph, which is indistinct, the toes are 
seen fully flexed. 



ATHETOSIS. 321 

The symptoms of athetosis are clearly indicated in the foregoing 
histories. Both cases came on with epileptic paroxysms — a feature 
accompanying other organic diseases of the brain and spinal cord. In 
both there are similar head-symptoms, tremulousness of the tongue, 
numbness on the affected side, pains in the spasmodically affected 
muscles, and especially complex movements of the fingers and toes, 
with a tendency to distortion. In neither case is there any paralysis. 

Cases of athetosis have now been reported in such numbers that 
further details in regard to them are scarcely necessary in this place. 
Eight in all have occurred in my own experience, and will be fully 
considered in a special monograph upon the subject. 

Morbid Anatomy and Pathology. — The view is generally held 
that athetosis and all other diseases which are characterized by mo- 
bile spasm are due to a lesion involving the cerebral motor pro- 
jection tract in some, or any, part of its course. I endeavored to 
show, a few years ago, 1 that such is not the case ; that where the 
motor conducting fibres are implicated by a lesion, the resulting 
spasm is spastic, and that mobile spasm is produced by the irritation 
of nerve-cells. 

The lesions which have been discovered in every case of athetosis 
in which an autopsy could be obtained substantiate this view. I 
have been enabled to collect the histories of thirteen cases of athe- 
tosis, in all of which autopsies were obtained. 

The first case, according to Brissaud, 2 was reported by Lauenstein. 
The lesion involved the posterior part of one thalamus. 

The second case was reported by Pick. 3 Here also the lesion was 
found to exist in the posterior portion of one thalamus. 

Grasset 4 reported the third case. In this instance there were 
three spots of softening — one on the inferior portion of the thalamus, 
one in a portion of the caudate nucleus, and one in the lenticular 
nucleus. 

The fourth case was one of Richet's, but was reported by Oul- 
mont. Here several spots of softening in different parts of the 
hemispheres were observed. There was also an area of softening 
which destroyed almost the entire posterior portion of the caudate 
nucleus, and another area which had made a deep cavity in the len- 
ticular nucleus. 

The fifth case came under the observation of Dr. Fletcher Beach. 5 
The microscope revealed an increase in number of the vessels, dis- 
tention of many of them, extensive infiltration of the tissue with leu- 

1 " Athetosis," Jour. Nerv. Mcnt. Dis., 1S86. 

2 Gazette hebdomadaire, 1880, p. 803. 

• 3 Prager Yierteljahrsdirift, 18*79, p. 141. 

4 Prog, med., Paris, November 13, 1880. 

5 Brit. Med. Journ., 18S0, i., 967. 
22 



322 DISEASES OF THE BRAIN. 

oocytes, especially in the perivascular sheaths of the vessels, and 
many of the vessels contained clots. These changes were principal- 
ly in the cortex of the inferior parietal lobule, and first tempero- 
sphenoidal convolution. 

In the sixth case, reported by Ringer, 1 a cyst was found occupy- 
ing the posterior part of the lenticular nucleus, and involving the 
white matter outside and beneath the thalamus and a small part of 
the thalamus itself. About one-fifth of the lenticular nucleus was 
destroyed, together with a few fibres of the internal capsule. 

The seventh case was reported by Landouzy. 2 The autopsy re- 
vealed a focus of softening in the lenticular nucleus on the left side. 
In the centre of this patch of softening a calculus about the size of a 
bean was found. 

The eighth case was reported by Dr. Murrell. 3 The whole right 
hemisphere w T as smaller and about three-quarters of an inch shorter than 
the left one. Almost the* entire lenticular nucleus was destroyed. 

The ninth case was reported by Emil Denange. 4 There was a 
large spot of softening on the cortex, which involved all that portion 
of the ascending parietal convolution in which Ferrier locates centres 
for complex movements of the fingers and hand. 

The tenth case is particularly interesting from the fact that it is 
the report on the autopsy of the original case whose history is related 
in the preceding pages of this chapter. He had suffered from the 
disease for twenty-two years. The athetoic movements involved the 
right foot and the right hand. There was no paralysis ; on the con- 
trary, the muscles of the forearm and leg were abnormally developed. 
There was, however, a certain amount of stiffness and rigidity of the 
muscles, which became quite apparent when he attempted to walk or 
to use his arm. Epileptic convulsions were of frequent occurrence 
from the very incipiency of the disease. They were very severe, and 
sometimes took that form known as " double consciousness." In one 
of these attacks of epilepsy he died. The brain could not be obtained 
till forty-eight hours after death. There was nothing suggestive of 
any pathological abnormality in the skull, the membranes, or the sur- 
face of the brain. 

As the cerebral substance was somewhat softened, the hemispheres 
were carefully cut, after Binot's method, into sections of about half 
an inch in thickness, and each section was then carefully hardened in 
Mtiller's fluid. As the left hemisphere was cut, a dense hardened 
mass was encountered in the region of the basal ganglia. No other 
gross lesion could be discovered. When the sections were sufficiently 
hardened, they were photographed, and were then sent to Dr. E. C. 
Spitzka for examination. 

1 Practitioner, London, September, 18*79. 2 Projres med., 1878, Nos. 5 and 6. 

3 Lancet, London, 1879, i., 369. 4 Revue de med., Paris, May, 1883. 



r o s- a-* 




a fe= 3 £ 6fei 3 




ATHETOSIS. 323 

Dr. Spitzka's report is as follows : " The lesion consists of a firm 
resistent fibrillar .connective-tissue mass, which, both at the anterior 
and posterior levels, did not yield to the knife, but came out bodily 
from the soft (post-mortem softened) normal tissue, in which it ap- 
peared to have been loosely imbedded. It extended antero-posteriorly 
from the ventral third of the caudate nucleus, at the level of the an- 
terior division of the internal capsule, which it also invaded, directly 
backward to the point where the capsule begins to collect its fibres 
to form the crus, at about the level of the mammillary bodies, here 
invading the thalamus proper (outer nucleus and reticular stratum 
of same), nearly obliterating the subthalamic region (body of Luys 
and zona incerta), extending across the capsule fibres, and encroach- 
ing on the inner and middle articuli of the lenticular nucleus, at their 
attenuated posterior ends. The thalamus and subthalamic regions in 
their aggregate had suffered a diminution in bulk of one third their 
mass, which was noticeable mostly in the vertical extent." 

The accompanying illustrations (Fig. 24), taken from drawings 
made by Dr. Spitzka, accurately depict the situation of the lesion. 

It will therefore be understood, from what has just been said, that 
the direct motor tract in the internal capsule was not involved to any 
extent. Lesions which affect that part of the caudate nucleus which 
was involved in this case have not been accompanied by athetosis. 
The probability is, therefore, that the symptoms observed depended 
upon the situation of the lesion in the thalamus and in the subthalamic 
region. In the following case the thalamus was severely injured, while 
the lesion in the lenticular nucleus was slight ; and in the twelfth case 
the corpus striatum was uot affected at all. 

The eleventh case was reported by Dr. E. C. Spitzka. 1 In this 
case the situation of the lesion corresponded accurately to the lesion 
in my own ease — that is, the posterior part of the thalamus, the pos- 
terior extremity of the internal capsule, and the outer part of the len- 
ticular nucleus were diseased, while the motor tract escaped uninjured. 

The twelfth, case was reported by Dr. E. C. Seguin, 2 and was 
described by him as a case of atheto-choreic spasm of the right side of 
the body. The lesion was found to be a glioma of the left thalamus 
and adjacent internal capsule. 

The thirteenth case is reported by Conto. 3 In this instance the 
athetosis was limited to one arm. The lesion discovered was a degen- 
eration of the cortex of the so-called arm centre. 

From a study of these cases it will be observed that in not a single 
instance was the lesion confined to the motor tract. On the contrary, 
whether the motor or the sensory tract were implicated or not, in every 

1 Meeting of the American Neurological Association, June 6, 1890. 

2 Ibid. 

3 Brazil Med.. Rio dc Janeiro, 18S9, iv., 25, 



324 DISEASES OF THE BRAIN. 

case either the cortex, the thalamus, or the striatum were discovered 
to be diseased. Lesions of the direct motor tract, between the cortex 
and the basal ganglia, such as abscesses, tumors, or haemorrhages, are 
not of infrequent occurrence, but no case has yet been reported where 
such a lesion has been followed by athetosis or any other form of mobile 
spasm. Where the motor tract is implicated there will be hemiplegia, 
spastic spasm, and exaggerated reflexes in addition to the athetosis. 
Where the sensory tract is involved, pain, numbness, tingling, or anaes- 
thesia will accompany the athetosis. In all of these cases, however, one 
or both of the basal ganglia or the cortical motor centres were diseased. 

Athetosis cannot be attributed to disease of the sensory tract, 
because in many instances this portion of the brain is found to be 
perfectly healthy. 

Since, therefore, brains of athetoic patients are found without lesions 
of the motor tract, and since others have been observed without lesions 
of the sensory tract, while in all cases one or both of the basal ganglia 
or the cerebral motor cortex are invariably diseased, there is only one 
conclusion to be reached, and that is that athetosis is due to an irrita- 
tive lesion of either the thalamus, the striatum, or the motor cortex. 

It would appear, therefore, that athetosis is a distinct pathological 
entity. 

Relative to the confounding of the affection with post-hemiplegic 
chorea, as has been done by Charcot and others, I have only to say 
that the distinction between the two conditions is as well marked as 
between chorea and disseminated cerebro-spinal sclerosis. In athe- 
tosis the movements are slow, apparently determinate, systematic, 
and uniform ; in post-hemiplegic chorea they are irregular, jerking, 
variable, and quick. Moreover, athetosis is not by any means neces- 
sarily post-hemiplegic. In the original case there had never been 
hemiplegia, nor was there such a state in the second case, on which 
my description of the disease was based. Of the eight cases which 
have occurred in my experience, hemiplegia was not an antecedent 
condition in four. 

Neither is it necessarily confined to one side of. the body ; cases of 
double athetosis, without hemiplegia, having been reported by Oul- 
mont 1 and Brousse, 2 in which there was probably general cerebral 
atrophy. 

It is no matter for surprise that many of the cases regarded as 
being athetosis are not instances of that affection. This is certainly 
the case with many of those reported by Dr. Clay Shaw, MM. Grasset, 
Charcot, and others. A similar event took place when aphasia was 
first prominently brought to the notice of the medical profession. 
Every case of loss or impairment of the faculty of speech, whether 
from paralysis of the tongue or lips, or other cause, was considered by 

1 Op. tit. 2 Op. tit. 



CEREBRAL SYPHILIS. 325 

some authors to be a case of aphasia. It was not till the disease be- 
came well known that these errors ceased to be made. 

Treatment. — From the nature of the lesions discovered post-mor- 
tem, it would be absurd to consider any medicinal treatment for this 
disease. There is one means, however, of alleviating the spasms for a 
long time, and possibly of arresting them altogether. This effect can 
be produced by stretching the appropriate nerves in the limb affected. 
Dr. TV. J. Morton ' was the first to perform this operation for this dis- 
ease. In his case such force was used as to render the limb permanent- 
ly paralyzed. I performed the operation three times on the patient 
whose symptoms led me to describe this disease. The median nerve was 
stretched in each instance. After every operation the spasms ceased 
entirely in both arm and leg, and the pain, which was severe, disap- 
peared. Complete relief was obtained after the first operation for four 
months ; then the pain and athetosis gradually returned. In his re- 
lieved condition I presented him before the New York Neurological 
Society. After an interval of a year I operated for the second time. 
Again he was free from every symptom of his disease for four months, 
and it was fully eight months before the disease was as severe as it 
formerly was. After the third operation more benefit was derived 
than from either of the others. For eighteen months not a trace of 
athetosis was visible. He could use his hand for writing, dressing him- 
self, eating, and in fact for almost any purpose. The muscles of the 
hand, arm, and foot were perfectly under the control of the will. 

Griedenburg 2 reports a case which was operated upon by Fricke. 
" The median nerve was stretched. Immediately after the opera- 
tion, and on the following day, no movements were noticed. On the 
second day after the operation the athetosis reappeared, and on the 
fourth day the movements had regained their former intensity." It 
is quite likely that subsequent operations would have been attended 
with longer intervals of rest. It seems to me that nerve-stretching 
holds out the only hope of relief. 



CHAPTER XYI. 

CEREBRAL SYPHILIS. 



Although the relations of syphilis to diseases of the brain have 
been considered in the foregoing chapters, it seems advisable to treat 
the subject with more particularity under its own special head. In so 
doing I shall avail myself to a great extent of the excellent epitome of 

1 Journ. Nerv. and Meni. Dis., 1882, K S., vii. 

2 " Vier Falle von Athetose," St. Petersburg med. Woc7i., 1882, vii. 



326 DISEASES OF THE BRAIN. 

the matter by Dr. Labadie-Lagrave, in the appendix to the French edi- 
tion of this work. 

ANATOMICAL LESIONS. 

a. Neoplasms — Hyperplasia of the Connective Tissue. 

At the autopsy of individuals who, in the course of a constitutional 
syphilis, have presented brain troubles, the lesions which are discovered 
in the intra-cranial organs for the most part consist of syphilomata or 
gummy tumors. As Virchow has stated, these may be either hyper- 
plastic forms by excess of normal growths, or they may be hetroplas- 
tic — that is, constituted of substance not normal to the position in 
which it is found. 

The neoplasm is sometimes diffused and sometimes more or less 
exactly circumscribed. According to my experience, the latter is 
much the more common form. It may present to the naked eye two 
different aspects, and both of these may exist in the same subject. 
Thus sometimes the new growth is of a gelatiniform consistence, of 
a more or less grayish-red color, and is lost imperceptibly in the sur- 
rounding tissues. Again, it forms a dense mass of cartilaginous con- 
sistence, brittle, and showing, when a section is made through it, a 
homogeneous caseous appearance. These yellowish-colored masses 
are entirely isolated and completely circumscribed. They are pro- 
vided with a fibroid covering. 

Sometimes they are found as small striated nuclei scattered through 
the reddish gelatiniform exudation. 

Of these two varieties of syphilomata, the second seems to be de- 
rived from the first. It is formed of a basis of connective tissue, more 
or less altered, in the meshes of which are perceived nuclei and rounded 
cells. It is probably as a consequence of atrophic degeneration of 
their elements that the soft and reddish masses are transformed into 
tumors of a yellowish color and of considerable consistence. Syphilo- 
mata of the nervous centres have special predilection for two intra- 
cranial situations : the dura mater and the sub-arachnoid space. Ac- 
cording to M. Fournier, 1 cerebral gummata are, in the great majority 
of cases, peripheric — that is, they are located in the cortical layer of 
the hemispheres. It is rarely the case that they are found in the 
central regions, and, when this is the case, it is almost always the gray 
substance — optic thalamus and corpus striatum — that they select. They 
are also much more commonly found in the anterior region of the 
brain than in the posterior, and at the base, especially its middle por- 
tion, than at the vertex. 

When they have their point of departure in the dura mater, they 
are developed between two thin laminae of this membrane, and their 

1 "La syphilis du cerveau," Paris, 1879, p. 57. 



CEREBRAL SYPHILIS. 327 

size varies from that of a pigeon's egg to that of a hen's egg. The 
action of such a growth upon the brain is that of simple compression. 

When, however, the neoplasm is developed primarily in the sub- 
arachnoid space, it invades all the organs (vessels, nervous tissue, etc.) 
by which it is surrounded, pressing the pia mater before it into the 
substance of the brain. The greater number of syphilomata met with 
in the tissue of the brain have this origin. The neoplasm may, more- 
over, lose its circumscribed form and assume the character of a diffused 
infiltration. It is very rarely that it appears as miliary nodosities sit- 
uated in the dura mater or the other membranes. Engelstedt has pub- 
lished a case of this kind, as have also Leon Gros and Lancereaux. 

Aside from these hyperplasia it does not appear that syphilis has 
power to produce an encephalitis passing on to softening or suppura- 
tion. A syphilitic caries of a cranial bone may give rise to a suppura- 
tion which is propagated to the dura mater and cerebral tissue, or a 
gumma or an alteration of arterial vessels, such as will presently be 
considered, may be the point of departure for a formation of pus or a 
simple softening. But, judging from the minute analysis of facts ad- 
duced by Heubner, 1 it has never been demonstrated that, taking these 
circumstances out of the question, there is ever developed a true syph- 
ilitic encephalitis. 

b. Syphilitic Alterations of the Arteries of the ^Encephalon. 

The alterations which syphilis may produce in the arteries of the 
encephalon are numerous. It is only recently that they have attracted 
the attention of pathologists, and are even yet very imperfectly known. 

In 1863 Wilks pointed out the existence of a gummy arteritis, 
of which since then the macroscopic characteristics have been well 
studied by different English authors, especially by Dr. Hughlings 
Jackson. This latter observer noticed, as did also others, that gummy 
arteritis is often the cause of thrombosis and softening of the tissue of 
the encephalon. 

Quite recently a German author, Heubner, has described a new 
variety of syphilitic arteritis. The lesions which characterize it are 
seated immediately under the inner coat of the artery, between the 
endothelium and the fenestrated membrane. They involve, therefore, 
the more vascular part of the arterial wall. They consist, in the be- 
ginning, of an active proliferation of the cellular elements of the en- 
dothelium, of which the products constitute nodosities which raise the 
internal coat of the artery, more or less obliterating the calibre and 
giving rise to thrombosis. The neoplasm sometimes becomes vascular 
and forms a veritable neomembrane under the endothelium, and some- 
times undergoes inodulary retraction, causing narrowing or even com- 
plete closure of the vessel. 

: "Die luetische Evkraukung der Hirnarterien," Leipzig, 18*74. 



328 DISEASES OF TIIE BRAIN. 

In addition, MM. Charcot and Pitres have shown, by the autopsy 
of a woman who at the time of her death exhibited undeniable syphi- 
litic cutaneous manifestations, the alterations produced by nodulated 
periarteritis in the arteries of the encephalon. 

The several steps in the morbid process as it affects the cerebral 
arteries are far from being known. M. Hanot, in a recent work on 
the subject, has well put the questions : What are the relations in evo- 
lution between gummata and the endarteritis of Heubner ? Must we 
admit that this arteritis is definitely established ? Are we warranted 
in placing periarteritis near it as another form of syphilitic arteritis ? 
These are questions which future researches will not fail to elucidate. 

c. /Syphilitic Meningitis. 

Under the heads of " Chronic Verticalar Meningitis " and " Chronic 
Basilar Meningitis" the relations of syphilis to inflammation of the 
membranes of the brain have been considered with some degree of 
fulness, and there is accordingly not much to say in this place. 

We have seen, too, that the great majority of gummata within the 
cranium have their origin in the membranes, and particularly in the 
dura mater and the subarachnoid tissue. According to M. Alfred 
Fournier, there can also be developed under the influence of syphilis a 
pachymeningitis and a hyperplasic piameritis, differing in no essen- 
tial respects from the ordinary inflammations of the dura and pia 
mater, so far at least as their histology is concerned. Heubner, how- 
ever, denies that these conditions ever exist. According to the German 
author, there is no case on record in which the altered membranes were 
submitted to rigid microscopical examination with the result of dem- 
onstrating the existence of this simple hyperplasic inflammation in cases 
of cerebral syphilis. To the naked eye, the remains of a gummy men- 
ingitis may present some signs of such a disease, but the microscope 
can alone afford satisfactory evidence of their real nature. 

Sometimes there are adherences between the membranes them- 
selves, and again adhesions of the membranes to the cortical substance 
of the brain. Indeed, whenever the pia mater is the seat of syphilitic 
inflammation, it can not be separated from the cortex without violence 
and resultant tearing away of the gray tissue. 

Syphilitic patients have died after having exhibited grave cerebral 
symptoms, and in whom after death no lesions could be found. Heub- 
ner mentions several such cases, and two have come under my own 
observation. 

Besides the growths of the brain or its membranes, it must be 
borne in mind that the endocranium may be the seat of the morbid 
formation. In his excellent work on cerebral syphilis, Dr. Dowse * gives 
two cases of what were probably instances of this kind ; and most phy- 

1 "Syphilis of the Brain and Spinal Cord," London and New York, 1879, p. 18. 



CEREBRAL SYPHILIS. 329 

sicians whose practice throws them in the way of seeing cases of brain 
syphilis have witnessed others similar. Subsequently ' Dr. Dowse says: 
" In the examinations which I have made of the brain after death 
(over one thousand), I have been surprised to find in how small a num- 
ber this disease appeared to originate in the under layer of the peri- 
osteum of the endocranium. I think this may perhaps be accounted 
for by the fact that where a gumma of the inner table of the skull does 
arise, the clinical features as evidenced by pain, etc., are so marked (for 
these manifestations usually occur with the existence of external gum- 
mata) that remedial measures are adopted early, and thus promote 
absorption before the membranes of the brain become involved." 

ETIOLOGY. 

The cerebral manifestations of syphilis are very common. They 
may show themselves at the beginning of the secondary period, but 
generally a much longer time — often many years — after primary infec- 
tion elapses before they appear. Certain circumstances favor the 
development of cerebral syphilis. Among them are bad specific treat- 
ment, preexisting nervous affections, emotional disturbances, excesses of 
all kinds, and generally every cause capable of weakening the nervous 
system. Quite recently I had a case under my charge in which the 
patient, a gentleman fifty years of age, was suddenly attacked with 
pain in the head, vertigo, and paralysis of the left third nerve, imme- 
diately after a period of great excitement in Wall Street. Upon in- 
quiry I ascertained that before his marriage, twenty-five years previ- 
ously, he had been treated for a hard chancre, but had never had any 
symptoms of constitutional syphilis except a cutaneous eruption during 
the first year after infection. Under the use of mercury and iodide of 
potassium the brain symptoms entirely disappeared in a few weeks. 

Virchow has expressed the opinion that the localization of syphilitic 
manifestations depends in many cases on noxious external influences. 
Thus we sometimes see the appearances of such essential phenomena 
soon after the inception of an injury of the cranium ; and it has long 
been thought that hydrargyrum might be the cause of an inflamma- 
tion or softening of the encephalon. 

Age is without sj:)ecial influence in the development of cerebral syph- 
ilis, and the same may be said of sex. 

GEXEKAL SYMPTOMATOLOGY. 

The variety in the situation and in the nature of syphilitic lesions 
of the encephalon causes great differences in their symptomatology. 
A prodromatic sign of much value on account of its constancy is head- 
ache. This symptom is always worthy of great attention, for it often 

1 Op. cit, p. 104. 



330 DISEASES OF THE BRAIN. 

precedes for a long time the appearance of more grave manifestations; 
for it is of great importance to prevent the development of conditions 
which it may be difficult to remove. " It is everything," says M. Four- 
nier, "to recognize cerebral syphilis in its beginning and to discover its 
origin." 

According to this judicious observer, headache, when prodromatic 
of cerebral syphilis, presents itself under the three following types : 

1. Severe pain, with a sensation of weight. 

2. Constrictive pain, seeming to the patient as though the head 
were about to split open. 

3. Pains as if from blows with a hammer, instantaneous and ex- 
tremely severe. 

These several forms of headache may be met with in the same 
patient. Generally they are particularly manifested during the night, 
as is the case with osteoscopic pains. Without medical treatment, 
they may disappear after a few months to return again spontaneously. 
It is rarely the case that the pain occupies the whole head, being either 
unilateral or limited to the anterior or posterior region. It may even 
occupy a very circumscribed spot, and then presents all the character- 
istics of the clavus hystericus. According to M. A. Fournier, " a 
violent and intense pain in the head, with nocturnal exacerbations of 
long duration, chronic, and frequently recurring, is a symptom that 
almost invariably indicates the existence of syphilis, and which should 
always excite suspicion." 

It is proper to insist upon the following point : Headache is re- 
garded generally as an essentially prodromatic symptom in the sense 
that it has for its cause in many cases lesions of the walls of the cra- 
nium, and appears first at a time when the intracranial organs have 
not yet suffered morbid change (Hueter). Later, when the dura mater 
is involved, the headache becomes more obstinate, more fixed, and is 
then no longer a prodromatic symptom. It is cerebral syphilis itself. 

Among the other symptoms, insomnia must be placed in the front 
rank. It may depend directly upon the cephalalgia, but is often ob- 
served when there is no pain in the head. This Symptom especially 
demands attention when it is met with in young subjects. 

Among the other phenomena are vertigo and sensations of faint- 
ness, a feeling of weight in the head, failure of memory, difficulty in 
concentrating the attention and forming ideas, and even aberration of 
the faculty of speech, either as a forgetfulness of words or an embar- 
rassment in pronouncing them properly. Sometimes there are great 
intellectual and moral depression, and, again, there is undue mental 
exaltation. These conditions may be combined in the same individual, 
alternating with each other ; often they are so slight as not to attract 
the attention of the patient, who does not consult a physician till some 
more grave symptom, such as an epileptiform seizure, alarms him. 



CEREBRAL SYPHILIS. 331 

Such attacks may supervene, while there is every appearance of excel- 
lent health, and may recur at distant intervals. In general, the later 
they are in appearing, the more persistent they are in remaining. 
Sometimes the paroxysm is not to be distinguished from one of true 
epilepsy ; at other times it lacks the initial cry or the convulsive move- 
ments, or is limited to one side of the head, as in symptomatic epilepsy. 
Quite often the convulsive crisis is followed immediately by the phe- 
nomena of motor paralysis. A syphilitic epilepsy may only be mani- 
fested under the form of the petit mat. 

M. Alfred Fournier has insisted, in his lectures on this subject, 
that in many cases of syphilitic epilepsy there are no pathognomonic 
characteristics distinguishing the attack from one of common epilepsy 
— that it is an error to assert, as have some authorities, that in syphi- 
litic epilepsy the paroxysms are particularly apt to occur in the night, 
and that they follow each other with great rapidity for a while, and 
then cease for a long period. The only symptoms, according to him, 
are the following : 

The convulsive phenomena are complicated with other cerebral 
manifestations, such as paralysis of a cranial nerve or optic neuritis, 
which persists during the intervals between the attacks. 

The convulsions, instead of beginning in early life, do not appear 
till after puberty, and then subsequently to a constitutional syphilis, 
which has arrived at its secondary period. 

It is certainly true, as Mauriac ' declares, that epilepsy is not gener- 
ally among the earlier manifestations of cerebral syphilis. Neverthe- 
less, I have seen several cases in which an epileptic paroxysm was 
the very first evidence that the brain was involved. Mental troubles 
sometimes then appear as depressing feelings, consisting of a kind of 
intellectual torpor, which advances slowly, in which there is notable 
weakening of the memory, and which finally terminates in melancho- 
lia or mania. At other times the psychical phenomena pursue a rapid 
course, and consist of periods of great excitement, variability of 
character and disposition, hallucinations, and furious delirium. These 
troubles of the intelligence may degenerate into complete dementia. 
Bell has reported a case of insanity which existed in a syphilitic patient, 
which lasted two years, and was then cured by a mercurial treatment. 

It sometimes happens that cerebral syphilis is manifested under 
the form of general paralysis of the insane, though sometimes, as 
Wilks has asserted, the delire des grandeurs is absent. Fournier is of 
the opinion that while general paralysis may be developed in a syphi- 
litic lesion, it has not been demonstrated that syphilis exercises any 
influence in the production of this disease. According to the eminent 
physician of the Saint Louis Hospital, of Paris, the affection which 

1 "Memo-ire sur les affections syphilitiqucs precoces des centres nerveux," Paris, 1879, 
p. 162. 



332 DISEASES OF THE BRAIN. 

some have taken for general paralysis of the insane is only a common 
general paralysis, which admits of cure by proper anti-syphilitic treat- 
ment. However all this may be, it is certainly true that general 
paralysis of the insane is not infrequently developed in the course of 
constitutional syphilis, and that there is just as much reason for re- 
garding it as of syphilitic origin as epilepsy, or other manifestations 
of the disease, as it affects the brain 

Aphasia. — Troubles of speech are very frequent in the course of 
cerebral syphilis. They present themselves under variable aspects, some- 
times being of early appearance and again not coming till late. They 
may consist of only a slowness of speech, the articulation being explo- 
sive or staccato, as is the case in paralysis agitans ; at other times there is 
motor aphasia. This is shown by a difficulty in pronouncing words or 
of associating them in a sentence. Again, there may be word-deaf- 
ness, word-blindness, agraphia, or amnesia, these symptoms coinciding 
with the occurrence of lesions in the cortex, or just beneath it, in re- 
gions which have already been fully described in a previous chapter on 
aphasia. The lesions usually found consist of gummata, meningeal in- 
duration, and syphilitic arteritis with softening. It often happens that 
the aphasia disappears with as much suddenness as it is developed, in 
which case it is probably due to congestion in the course of the speech 
tract. Not long since I reported 1 an interesting case of this kind ; an- 
other is detailed in the present treatise (page 232) ; several have been 
given by Tarnowsky, 2 and Fournier 3 declares that when it occurs as an 
early manifestation of cerebral syphilis it is almost always ephemeral. 

Motor Paralysis. — The cortical lesions which give rise to aphasia 
frequently involve the neighboring motor zone. It is therefore not 
surprising to find syphilitic aphasia complicated with a more or less 
complete motor paralysis of the right side. But the paralysis due to 
syphilis of the brain may of course appear on either side of the body. 

It is rarely complete in the beginning. It advances slowly, with 
periods of amendment and of aggravation, and is complicated with 
convulsive seizures. It has, in fact, all the characteristics of cortical 
paralyses. It must be borne in mind that syphilitic lesions of the en- 
cephalon are most commonly met with in the membranes and in the 
cortical substance of the hemispheres (twelve out of fourteen, accord- 
ing to Jaksch). The paralysis of the limbs is often preceded by that 
of a cranial nerve. Thus, for example, a patient who is apparently in 
perfect health suddenly becomes the subject of ptosis, strabismus or di- 
plopia, and at other times of a diminution of visual power. Again., 
the muscles of the face are the seat of temporary contractions, or a 

1 "Syphilitic Aphasia; Neurological Contributions," No. 1, vol. i., New York, 18*79, 
p. 62. 

2 "Aphasie syphilitique," Paris, 1870. 

3 Op. cil, p. 242. 



CEREBRAL SYPHILIS. 333 

neuralgia of the fifth pair is developed. These phenomena, which 
may disappear and reappear many times, generally precede by several 
months, or even years, paralysis of the limbs. 

It is rarely the case that paralysis of syphilitic origin begins with 
an apoplectiform seizure. When this does occur, the apoplectic attack 
is generally the immediate result of some strong emotional disturbance 
or an alcoholic or venereal excess. In such cases the resemblance to 
hemiplegia from cerebral haemorrhage or embolism is complete ; but 
when it is complicated with decided syphilitic manifestations its spe- 
cific origin is extremely probable. M. Fournier asserts that seventy- 
five out of every one hundred cases of ocular paralysis are syphilitic; 
but it is probable that the proportion is not nearly so great as this, 
and, with M. Charcot, we must recognize the fact that many cases of 
such paralysis are the initial phenomena of locomotor ataxia. 

Troubles of vision are very frequent in the initial period of syphi- 
lis. According to M. Fournier, both eyes are generally affected, and 
the morbid process advances very rapidly. All degrees of weakness 
of vision, from a slight amblyopia to complete blindness, are observed. 
I have a case now in mind, which I saw in New Jersey a year ago, in 
which the blindness was so intense that the passage of a bright light 
before the eyes was not noticed, and yet in less than two months, 
under the use of large and increasing doses of iodide of potassium and 
the moderate use of mercury, the sight was entirely restored. Gener- 
ally these visual troubles are complicated with other phenomena, such 
as headache, convulsive seizures, etc. They depend upon optic neuri- 
tis, which offers to the ophthalmoscope no essential differences from 
the non-specific form of the affection. 

Derangements of the sense of hearing are also common among 
the early symptoms of cerebral syphilis. They are probably due to 
inflammation or congestion of the auditory nerves, and usually are 
met with in both cases. Like the visual troubles from like cause, they 
are, if not of too long duration, amenable to treatment, and sometimes 
disappear with great suddenness. 

The duration of cerebral syphilis depends upon the nature of the 
encephalic lesions and upon the treatment directed against it. Affec- 
tions of the arteries are the gravest in character, since they may re- 
sult in an apoplectic attack due to a thrombosis of one or more of the 
large vessels. Under such a circumstance the patient dies in a few 
days in a state of complete coma. Whatever may be the lesion, death 
may occur, and in fact does often supervene. On the contrary, a cure 
may be almost certainly obtained, more or less complete in character, 
when the proper treatment is initiated early and carried out with effi- 
ciency. 



334 DISEASES OF THE BKAIN. 

CHAPTER XVII. 

SYMPTOMATOLOGY OF CEREBRAL LESI02TS. 

I. 

CORTICAL PARALYSES. 

For a long time it was believed that the different regions of the 
cortical substance of the brain were endowed with the same functions, 
and that thought, memory, volition, and perception had a common re- 
lation to all parts of the gray substance forming the external surface 
of the convolutions. Flourens, studying the effects of partial disturb- 
ance of this gray substance, arrived at the conclusion that the results 
were the same whatever was the seat of the lesion. 

In 1864, as has already been brought to the notice of the reader, 
the researches of Broca demonstrated the existence of a special centre 
for language — a fact which Bouilland and Dax had previously done 
much to establish. This centre was shown to be situated either in the 
posterior part of the left third frontal convolution, or in the corre- 
sponding part of the right third frontal convolution, according as the 
individual was right- or left-handed. For a long time no further prog- 
ress was made in the direction of localization, and no one ventured 
to extend the discovery of Broca and to apply its principles to other 
functions, the seat of which, all agreed, was in the gray substance of the 
hemispheres. 

In 1870, the German physiologist Hitzig, applying a galvanic cur- 
rent to the gray substance of the hemispheres — until then regarded as 
inexcitable — saw, to his great astonishment, muscular contractions pro- 
duced in the opposite side of the body. Moreover, the galvanic excita- 
tion of the same part on the surface of the hemispheres always produced 
contractions in the same group of muscles. Such, in fact, were the rela- 
tions between the irritated region of the cerebral cortex and the groups 
of muscles which contracted under the influence of the excitation, that 
Ferrier, repeating on a monkey the experiments of Hitzig, before the 
Royal College of Physicians of London, has been able to predict what 
group of muscles he would cause to contract. 

These experimental results of Hitzig and Ferrier have caused a com- 
plete revolution in our views relative to the physiology of the brain, 
for they have shown that the gray substance forming the periphery of 
the hemispheres is not, as had been thought, inexcitable. And, on the 
other hand, the question of cerebral localization has received a degree 
of elucidation which has already led to a vast amplification of our knowl- 
edge of cerebral physiology and pathology. It is therefore scarcely 
a matter of doubt that the several groups of muscles of the body are 
in direct anatomical and physiological relation with as many ideomotor 



SYMPTOMATOLOGY OF CEREBRAL LESIONS. 335 

centres, occupying each its distinct position in the anterior regions of 
the gray matter of the convolutions. After performing a great many 
experiments, Hitzig arrived at the conclusion that the exact situation 
of each one of these centres was a matter of certainty. He assigned 
to them the ascending frontal convolution as common property. The 
superior part of this convolution contains the centres of movements 
for the lower extremity of the opposite side of the body. Passing 
downward, we come successively to the centre for the upper extremity, 
that for the face, and the centre for the movements of the lips and the 
tongue. 

But facts deduced from experiments contradictory of the results 
obtained by Hitzig were not slow in being brought forward. Sampt, 
supported by a case in which a cysticucus was situated in the ascending 
frontal convolution without giving rise to any troubles of motility 
of the opposite side, denied all connection between the functions of 
this convolution and voluntary motion. According to Goltz, the ef- 
fects consecutive to the destruction of a limited portion of the gray 
substance of the convolutions are not dependent on the seat, but only on 
the extent of the lesion. These effects would be the same whether the 
experiment were performed on the anterior or posterior part of the 
hemispheres, always, however, affecting not only motion, but general 
sensibility and vision as well. These results of Goltz, however, lose 
much of their value from the fact that the author, as he himself de- 
clares, practiced very considerable mutilations of the animals subjected 
to experiment. On the contrary, Ferrier, substituting galvanic or f ara- 
daic electricity as the exciting agent, found that there was undoubt- 
edly a motor zone in the anterior part of the gray substance of the 
hemispheres. He, however, limited the extent of this zone to about 
the anterior two thirds of the surface of the brain ; that is to say, to a 
space ten times larger than the space occupied by the ascending frontal 
convolution. Ferrier's results have been confirmed by MM. Carville 
and Duret, who have had recourse to an inverse process, they having 
studied not only the influence produced, by excitation, but also that 
caused by partial destruction of the cortical substance. 

The researches of Betz have given an anatomical basis to the theory 
of cerebral localizations. This observer, having submitted minute por- 
tions of the cortical substance of the hemispheres to microscopical ex- 
amination, discovered two regions which were distinguished from the 
rest of the convolutions by the presence of large pyramidal cells meas- 
uring mtn .12 in their long and mm .06 in their short diameter. The first 
of these regions embraced the anterior central convolution and- the 
superior part of the posterior central convolution as well as the para- 
central lobe. The second occupied a variable extent with different in- 
dividuals, reaching as far as the point of the occipital lobe. These 
larger ganglionic cells are particularly abundant about the right para- 



336 DISEASES OF THE BRAIN. 

central lobe. Betz is of the opinion that of these two regions the ante- 
rior corresponds to the motor zone, while the posterior is probably the 
centre for the perception of sensitive impressions. The gray substance 
of the convolutions appears, therefore, to be arranged and have func- 
tions corresponding to those of the gray matter of the spinal cord. 

If distinct motor centres, each having dependent upon it a certain 
group of muscles, really exists in the anterior part of the surface of the 
hemisphere, lesions destructive of the region of the cortex represent- 
ing one of these centres ought to produce paralysis of the muscles in 
relation therewith. 

This point has lately occupied the attention of pathologists, and it 
has been ascertained that the evidence supplied by pathological anat- 
omy and clinical observation points still more strongly than the results 
of experiment to the exactness of Hitzig's conclusions. 

Thus MM. Charcot and Pitres have collected in a remarkable work 
a certain number of cases going to show the relations existing between 
paralyses and distinctive lesions of the gray substance of the convolu- 
tions. In all these cases the seat of the cortical lesion was indicated 
with the utmost exactness. Hence they arrive at the conclusion that 
the cortex of the brain contains a motor zone, and that this motor zone 
occupies the paracentral lobe, the two ascending convolutions, and 
probably also the inferior portion of the three frontal convolutions. In 
the cases cited by MM. Charcot and Pitres, all cortical lesions, what- 
ever their extent outside of this motor zone, were powerless to cause 
troubles of motility. On the other hand, destructive lesions, even 
when of very limited extent, situated within this zone, constantly pro- 
duced motor disturbance. The paralysis was of sudden origin when 
the lesion had been suddenly produced, and it was limited to a part 
only of one side of the body when the lesion was restricted to a part 
only of the motor zone. MM. Charcot and Pitres, moreover, think 
they are warranted in concluding, from their study of paralyses and 
convulsions of cortical origin, that the motor centres for the upper and 
lower extremities are seated in the paracentral lobe of the opposite 
side and in the two upper thirds of the ascending convolutions, and that 
the centres for the movements of the lower part of the face are placed 
in the inferior third of the ascending convolutions in the vicinity of 
the fissure of Sylvius, and finally that it is very probable that the centre 
for isolated movements of the upper extremity is situated in the mid- 
dle third of the ascending frontal convolution of the opposite side. 

Quite recently MM. Charcot and Pitres have published a new mem- 
oir, in which they have collected a number of cases of cortical lesions 
situated exteriorly to the motor zone, and which have not produced 
any derangement of motion. From these facts, collected from different 
authors, these observers have drawn the following conclusions, which, 
it will be perceived, are in accordance with their own results : "There 



SYMPTOMATOLOGY OF CEREBRAL LESIONS. 337 




Side view of the brain of man and the areas of the cerebral convolutions. 
(After Eerrier.) 

1 (On the postero-parietal [superior parietal] lobule), advance of the opposite hind-limb as 
in walking. 2, 3, 4 (Around the upper extremity of the fissure of Rolando), complex 
movements of the opposite leg and arm, and of the trunk, as in swimming ; a, 6, c, d (on 
the postero-parietal [posterior central] convolution), individual and combined movements 
of the fingers and wrist of the opposite hand : prehensile movements. 5 (At the pos- 
terior extremity of the superior frontal convolution"), extension forward of the opposite 
arm and hand. 6 (On the upper part of the antero-parietal or ascending frontal [ante- 
rior central] convolution), supination and fiexion of the opposite fore-arm. 7 (On the 
median portion of the same convolution), retraction and elevation of the opposite angle 
of the mouth by means of the zygomatic muscles ; 8 (Lower down on the same convolu- 
tion), elevation of the ala nasi and upper lip with depression of the lower lip, on the 
opposite side. 9, 10 (At the inferior extremity of the same convolution, Broca's con- 
volution), opening of the mouth with 9, protrusion, and 10, retraction of the tongue — 
region of aphasia, bilateral action. 11 (Between 10 and the infeiior extremity of the 
postero-parietal 'convolution), retraction of the opposite angle of the mouth, the head 
turned slightly to one side. 12 (On the posterior portions of the superior and middle 
frontal convolutions), the eyes open widely, the pupils dilate, and the head and eyes 
turn toward the opposite side. 13, 13 (On the supra-marginal lobule and angular 
gyrus), the eyes move toward the opposite side with an upward 13, or downward 13, 
deviation ; the pupils generally contracted (centre of vision). 14 (Of the infra-mar- 
ginal, or superior [first] temporo-sphenoidal convolution), pricking of the opposite ear, 
the head and eyes turn to the opposite side, and the pupils dilate largely (centre of 
hearing). Ferrier, moreover, places the centres of taste and smell at the extremity of 
the temporo-sphenoidal lobe, and that of touch in the gyrus uncinatus and hippocam- 
pus major. (After Ranney.) 
23 



338 DISEASES OF THE BRAIN. 

exist in the cortex of the cerebral hemispheres, regions which have no 
relation with the power of motion, and in which, consequently, lesions 
may be produced without permanent trouble of the motor functions. 
These regions comprise the occipital lobe, the sphenoidal lobe, the an- 
terior part of the frontal lobe, the orbital lobe, the parietal lobes (except 
perhaps their feet), the quadrilateral lobe, and the cuneiform lobe." 

Experimental physiology and clinical observation agree that there 
exists on the periphery of the hemisphere a motor zone, embracing the 
pre-central gyrus, the post-central gyrus, and the posterior extremities 
of the three frontal gyri. At the same time it may be considered an 
established fact that electrical or pathological excitation of this zone 
engenders contractions of the muscles of the opposite side of the body, 
while destructive lesions involving this zone produce motor paralysis 
of the same muscles. But we can even go further than this, for in 
the present state of our knowledge it is quite possible for us to deduce 
from the seat of the paralysis the exact situation of the cortical lesion. 
It is more than probable that the motor zone, the existence of which is 
not a matter of doubt, is divided into a certain number of regions, each 
one having its distinct function. In other words, it can be freely con- 
ceded that a given group of muscles is under the exclusive control of 
a single ideomotor centre located in a determinate part of the motor 
zone. The different motor cells of this zone are in intimate relation 
with each other, and they communicate, on the other hand, with motor 
fibres which go to the contractile organs of the periphery. It is ap- 
parent, therefore, that when a portion of the motor centre is destroyed 
by a pathological alteration, the muscles which are paralyzed are those 
which are in anatomical connection with the cells situated in the dis- 
ordered part of the cortex. Now we have a very definite knowledge 
relative to the course of the motor fibres in the centrum ovale, and of 
their distribution to the periphery of the cortex. There is every proof 
that the fibres destined to a particular group of muscles come from 
neighboring cells of the motor zone. We must, therefore, conclude 
that there are various cortical centres, each one of which is connected 
directly with a particular set of muscles. Ferrier holds that these 
centres are limited by sharply demarked lines, but I think the evidence 
goes to show that Horsley's view—" that in one spot especially the rep- 
resentation is concentrated and thence diminishes gradually " — is the 
more correct. 

II. 

PARALYSES CONSECUTIVE TO CENTRAL LESIONS OF THE HEMISPHERES. 

The cerebral hemispheres, attached on each side to a corresponding 
peduncle, are composed of certain nuclei of gray matter (central gan- 
glia), among which pass laminae of white tissue, which constitute the 



SYMPTOMATOLOGY OF CEREBRAL LESIONS. 



339 



Fig. 26. 



greater part of the substance of which each lateral half of the brain is 
constructed. These gray nuclei are three on each side — the lenticular 
nucleus, the caudated nucleus, and the optic thalamus. The first two 
are sometimes designated the extra-ventricular and intra-ventricular 
nuclei respectively, and together constitute the corpus striatum. The 
caudated nucleus and the optic thalamus are separated from the 
lenticular muscles by a lamina of white 
substance called the internal capsule, 
which by its expansion constitutes the 
corona radiata. These relations are 
clearly shown in the accompanying 
diagram (Fig. 26) of a horizontal sec- 
tion of the brain. 

The internal capsule may, for con- 
venience, be divided into anterior and 
posterior halves, the line of demarka- 
tion being at the "knee" or bend. 
With the function of the anterior half 
we are as yet unacquainted, but with 
the posterior half our knowledge is 
more definite. The posterior third of 
the posterior half is composed exclu- 
sively of sensory fibres, which wind 
around the posterior extremity of the 
lenticular nucleus and terminate in the 
cortex. Ferrier and Horsley both con- 
sider that the gyrus fornicatus and the 
gyrus hippocampus contain the cortical 
centres for the cutaneous sensations. 
But other evidence, principally con- 
tributed by Munck, Exner, Luciani, and 
Sepilli, and ably condensed and aug- 
mented by Dana, 1 demonstrate almost 

conclusively that the termination of the sensory tract for the expres- 
sion of touch, pain, and temperature in the cortex is in the precen- 
tral and post-central gyri, and perhaps even a little posteriorly. This 
tract can be traced downward through the formatio reticularis in the 
medulla to the sensory tract in the spinal cord. The muscular sense is 
transmitted by fibres which apparently originate in the nucleus gracilis 
and nucleus cuneatus in the medulla. These nuclei are the termina- 
tions of Burdach's and Goll's columns in the spinal cord. This tract 
decussates in the medulla, and, passing up through the inter- olivary 
tract, joins the sensory tract in the internal capsule and terminates in 
centres situated in the parietal cortex. 

1 " Cortical Localizations of the Cutaneous Sensations," Journ. New. and Merit. Dis., 
Oct., 1888. 




Horizontal section through the brain, 
showing the internal capsule with 
its motor and sensory divisions. 
T 7 , tongue fibres. F, face fibres. 
A, arm fibres. Tr, trunk fibres. 
Z, lesr fibres. 



340 DISEASES OF THE BRAIN. 

The anterior two thirds of the posterior half of the internal capsule 
consists entirely of motor fibres. This tract terminates, on the one 
hand, in the cells of the motor centres of the cortex (Fig. 25), and on 
the other hand, after partly decussating in the pons, is continued in 
the lateral and anterior pyramidal tracts in the spinal cord. 

These statements of the anatomy of the parts concerned are 
necessary for the full comprehension of the morbid conditions induced 
by lesions of the different regions of the central mass of the hemi- 
spheres. 

a. Lesions of the Posterior Third of the Internal Capsule. 

Cerebral Haimi-anaisthesia. — When a lesion involves the posterior 
third of the posterior half of the internal capsule, that portion com- 
prised between the optic thalamus and the posterior part of the len- 
ticular nucleus, it is manifested by total hsemi-ansesthesia, both as re- 
gards the skin and the other organs of special sense, and is situated on 
the side opposite to that of the lesion. This is demonstrated by facts 
furnished by Andral, TtLrck, Rosenthal, Jackson, Charcot, Yulpian, 
Luys, Rendu, Veyssiere, and others. This general haemi-ansesthesia 
is explained when we call to mind the fact that the lenticulo-optic 
portion of the internal capsule contains all the sensorial fibres which 
come from the opposite side of the body. Experimental physiology 
confirms the data which are supplied by clinical experience and anat- 
omy. The researches of Yulpian, and of Duret and Veyssiere, his 
pupils, demonstrated that experimental lesions of the posterior third 
of the internal capsule produce complete hsemi-anajsthesia of the 
opposite side of the body. 

From a clinical stand-point hamii-ansesthesia of cerebral origin 
does not in any respect differ from the like condition induced by 
hysteria. In both cases general sensibility is abolished in one-half of 
the body, in all its different expressions, while at the same time the 
other special senses are abolished or deranged on the same side. As 
regards the sight in hysteria, there is not only a diminution of the 
power of vision which may be in one eye only, but there is a concen- 
tric and general narrowing of the visual field, with central scotomata, 
which are generally transient, while the color field is narrowed or 
else is entirely lost. 

In unilateral lesions of the hemispheres the theory of A. von Graef e, 
that the usual trouble observed is a simple abolition of sight in the 
corresponding field of vision of both eyes — in other words, a homony- 
mous lateral hemianopsia — is generally accepted. This can be readily 
comprehended when it is understood that the fibres of the optic tract 
originating in the right hemisphere go to the left half of each retina, 
and that the optic tract which arises from the left hemisphere supplies 
the right half of each retina (Fig. 27, page 346). 



. SYMPTOMATOLOGY OF CEREBRAL LESIONS. 341 

b. Lesions of the Anterior Two-Thirds of the Posterior Half of the 

Internal Capsule. 

Cerebral Hemiplegia, Secondary Degeneration, Late Contraction, 
— Every destructive lesion limited to the anterior two-thirds of the 
posterior half of the internal capsule causes symptoms of common 
cerebral hemiplegia, otherwise known as motor paralysis, and affect- 
ing the side opposite to the lesion. When the lesion is situated so as 
to involve the entire posterior half of the internal capsule, we have at 
the same time the symptoms of motor hemiplegia, associated with the 
phenomena of haami-anaBsthesia described in the immediately preced- 
ing section. 

A motor hemiplegia consecutive to a destructive lesion of the in- 
ternal capsule is in general very decided, and more or less persistent 
in character. Moreover, at an advanced stage it is almost invariably 
complicated with permanent contractions of the paralyzed limbs, as 
happens in profound lesions of the motor zone of the convolutions and 
of the subjacent white substance. These contractions are directly due, 
as already stated, to secondary degeneration of the pyramidal motor 
fibres, which, crossing from the fronto -parietal region of the centrum 
ovale of each hemisphere, reach without interruption the posterior part 
of the lateral column of the spinal cord of the opposite side and the 
anterior column of the same side by passing through the two anterior 
thirds of the posterior half of the internal capsule. 

The appearance of late contractions is always an unfavorable cir- 
cumstance in determining the prognosis. It indicates, in fact, that 
the hemiplegia is due to a lesion of the internal capsule, and that, 
moreover, our therapeutical measures are generally powerless against 
the hemiplegia which has resulted. At the same time it is not to be 
doubted that even in these cases ameliorations can be sometimes pro- 
duced by appropriate treatment. 

c. Lesions of the Central Ganglia of the Hemispheres. 

Transitory Hemiplegia. — Lesions confined to the central ganglia 
of the hemispheres (lenticular nucleus, nucleus caudatus, and optic 
thalamus) also produce motor paralysis. But this is, in general, of 
a transient character, and is probably never followed by late contrac- 
tions. 

To explain the non-permanent duration of a hemiplegia confined to 
the gray nuclei of the hemispheres, it has been said that the different 
parts of these centres can replace each other in function. Would it 
not, however, be more natural to admit that the central ganglia do not 
take a direct part in the execution of voluntary movements? On the 
one side it is demonstrated that the motor zone of the convolutions 
originates voluntary motor impulses, and is directly in anatomical re- 



342 DISEASES OF THE BRAIN. 

lation with the motor centres of the spinal cord. On the other side, 
there is no case on record in which a lesion limited to the substance 
of one of these gray nuclei has given rise to secondary degeneration. 
On the contrary, Tiirck has noticed a lesion the size of a filbert seated 
in the body of the nucleus caudatus which had not produced a sec- 
ondary degeneration. In two other cases reported by Tiirck, a lesion 
of old date occupied the superior part of the optic thalamus, and in 
neither of them was there secondary degeneration. This absence of 
secondary degeneration has likewise been noted by Flechsig in two 
cases, in which a circumscribed lesion was limited to the external zone 
of the lenticular nucleus. The central ganglia of the hemispheres 
seem, then, to be deprived of all direct connection with the direct 
pyramidal fibres interposed between the cortical motor zone and the 
motor cells of the spinal cord. 

Moreover, to explain the development of transient motor hemiple- 
gia consecutive to lesions in the substance of the central ganglia, 
we are led to admit that these lesions act only by compression in 
abolishing for a short time the functions of the pyramidal fibres of 
the internal capsule whose office it is to transmit voluntary motor 
impulses. 

Hemi-mobile Spasm of Cerebral Origin. — A few years since, Dr. 
Weir Mitchell pointed out for the first time that choreiform troubles 
sometimes complicate the muscular paralysis in patients who have 
for some time been the subjects of hemiplegia. He gave to this 
condition the name of post-hemiplegic chorea. More recently M. 
Charcot has shown the frequent co-existence of hemichorea with 
hsemi-anaesthesia of cerebral origin. Explaining this co-existence by 
the results of a certain number of autopsies, he has demonstrated that 
the lesions which cause these two varieties of phenomena — haemi- 
ansesthesia and hemichorea — occupy contiguous points of the posterior 
part of the foot of the corona radiata — the lesions which have been 
found at the autopsy of patients affected with hemichorea being com- 
prised in the zone which includes the posterior part of the internal 
capsule, the posterior part of the optic thalamus and of the caudated 
nucleus, and the anterior tubercula quadrigemina. But M. Charcot is 
of the opinion that the lesion of the white substance — that is to say, 
of the internal capsule — is that to which the hemichorea supervening 
in hemiplegia is to be ascribed ; and this view is likewise held by the 
majority of neurologists, but it seems to me to be erroneous, and that 
the true lesion is of an irritative nature and is seated within the basal 
ganglia. Hemichorea, hemiathetosis, hemiparalysis agitans, and all 
other forms of hemi-mobile spasms differ from each other in degree 
only, and not in nature. It is to be remembered that this hemispasm 
is not always post-hemiplegic, but that it may precede an attack of 
cerebral haemorrhage. 



SYMPTOMATOLOGY OF CEREBRAL LESIOXS. 343 

d. Lesions of the Lateral Ventricles ; Ventricular Hwmorrhage. 

Convulsions of Central Origin — Early Contraction. — When a 
hemorrhagic extravasation breaks through into the cavity of the ven- 
tricles, it occasions at the same time coma, paralysis, early contrac- 
tions, and epileptiform convulsions. 



III. 

LESIONS OF THE TUBERCULA QUADRIGEMINA — OCULO-PUPILLARY 

TROUBLES. 

It is generally admitted that the tubercula quadrigemina have no 
connection with the visual sense. The influence of the anterior pair 
of these organs over the movements of the pupil has been thoroughly 
demonstrated. Flourens, for instance, obtained movements of the iris 
on both sides by exciting the tubercula quadrigemina ; and, more re- 
cently, Ferrier, by electrizing these nuclei of gray substance, has seen 
the pupils dilate. 

In addition, the anterior pair of the tubercula quadrigemina preside 
over the conjugate movements of the eyeballs. This is shown clearly by 
the researches of Adamtik, published in 1870. This physiologist has 
shown that the superficial excitation of the anterior pair of the tuber- 
cula quadrigemina at different points produces varied movements, but 
that always both eyes move simultaneously. When the right tuber- 
culum is excited, both eyes deviate to the left ; when, on the other 
hand, the left is excited, both eyes are turned to the right. 

These physiological data have found their application in the pa- 
thology of the nervous system. In a certain number of cases of the 
destruction of the tubercula quadrigemina of both sides, complete 
blindness with dilatation of the pupils has been produced. Thus, in 
the case of a patient observed in the service of M. Pidoux by M. Blan- 
quinque, 1 and in which during life complete blindness and dilatation 
of the pupils were present, at the autopsy was found a tumor of the 
pineal gland, which compressed both pairs of tubercula quadrigemina, 
especially the posterior pair. In the same patient the eyes were 
turned downward and to the right. This phenomenon of the conju- 
gate deviation of the eyes is also observed as a consequence of lesions 
affecting very different points of the nervous centres. It is of such 
great importance in its diagnostic relations to encephalic lesions 
that the study of its semeiological value may properly engage our 
attention. 

Conjugate Deviation of the Eyes. — Before Adamiik discovered in 
the two anterior tubercula quadrigemina the centres for the move- 

1 Gazette hebdomadaire, No. 33, 1871. 



344 DISEASES OF THE BRAIN. 

ments of the eyeballs, Magendie had established the fact that these 
movements are under the influence of the middle cerebellar peduncles. 
This illustrious physiologist, having divided in a hare the middle cere- 
bellar peduncle of one side, saw the corresponding eye turn downward 
and become more prominent, while the eye of the sound side turned 
upward and retreated within the orbit. The eyes resumed their nor- 
mal positions as soon as Flourens divided the middle cerebellar pedun- 
cle of the other side. Longet and Schiff, on repeating Flourens's ex- 
periment, arrived at a like result. This last observer noticed that, 
when the experimental lesion involved not only the cerebellar pedun- 
cle but the lateral region of the cerebellum, the conjugate deviation 
was still produced, but with an inverse disposition ; that is, the eye of 
the sound side protruded and was turned downward, while the eye of 
the injured side became less prominent and turned upward. A simi- 
lar fact had already been observed in 1826 by Hertwig. 

More recently, Curschmann has contended that the conjugate de- 
viation of the eyes, such as had been observed by Flourens, is not the 
result of section of the cerebellar peduncles, and that this devia- 
tion is only produced if the lesion concerns a point in the hemi- 
spheres of the cerebellum, which in the hare is known as the acoustic 
tubercle. 

Hitzig, who experimented on rabbits, obtained conjugate deviation 
of the eyes by applying the two poles of a galvanic pile to the poste- 
rior lobe of the vermis. Both eyes deviated to the right or to the 
left according as the positive pole was applied to the right or the left. 
When the two electrodes came in contact on the superior lobe of the 
vermis, one of the eyes turned upward and the other downward, ac- 
cording to the direction of the current. 

Finally, Ferrier has seen, when the most anterior part of the ver- 
mis was electrically excited, both eyes deviate, that of the right side 
outward, and that of the left inward. By exciting the middle or in- 
ferior part of the vermis, the character of the deviation was reversed. 
By exciting the cerebellum at various points in the monkey, the dog, 
and the cat, Ferrier was constantly able to produce conjugate devia- 
tion of the eyes, the direction of the deviation varying according to 
the point excited. In general terms, it may be said that the organs, 
the excitation of which produces the phenomenon in question, are the 
tubercula quadrigemina and the cerebellum and its expansions. 

Moreover, we see that unilateral lesions of any point whatever of 
these organs are equally accompanied by conjugate deviation. In 
fact, if the ocular globes are cut off from the influence of one of the 
two homologous centres which preside over their associated move- 
ments, the influence of the unaffected centre will alone be felt, and the 
two eyes will take the same anomalous position that would be pro- 
duced by excitation of a symmetrical point. Clinical experience fully 
justifies these physiological deductions. For a long time it has been 



SYMPTOMATOLOGY OF CEREBRAL LESIONS. 345 

known that lesions situated in the vicinity of the isthmus of the en- 
cephalon cause during life hemiplegia, with conjugate deviation of the 
eyes, accompanied often with a rotation of the head on its axis. In 
regard to the direction of the deviation, it is variable, sometimes be- 
ing toward the side on which the lesion is situated, and sometimes 
toward the opposite side. But this phenomenon of the conjugate de- 
viation of the eyes, with or without rotation of the head, is observed 
in the cases of lesions affecting very different parts of the cerebral hemi- 
spheres. Very often the phenomenon is due to a restricted lesion in 
the vicinity of the corpus striatum and peduncular expansion. M. Pre- 
vost 1 has endeavored to lay down a general law to the effect that, in 
a case of cerebral lesion, the conjugate deviation of the eyes is always 
from the affected side. But a case reported by Duplay, and four oth- 
ers by Eichhorst, demonstrate that the contrary direction may exist, 
and that consequently the rule enunciated by Prevost is too absolute. 

IV. 

LESIONS OF THE OPTIC TRACTS. 

Lateral Hemianopsia. — As we have seen, according to the theory 
generally admitted, the nerve-fibres which form the optic nerves only 
partially decussate in the chiasma. Those which cross over from one 
side to the other are, of course, the nearest to the median line, and 
occupy the most internal part of the nerve and optic tract of each side. 
On the other hand, those fibres which do not cross occupy the most 
external part of the nerve and tract. An examination of the draw- 
ing (Fig. 27) will make these statements clear, and will establish the 
fact that the nerve-fibres which form each tract pass to the correspond- 
ing half of each retina. Thus the fibres of the left optic tract pass to 
the left half of each retina, and those of the right to the right half. 

This explanation of the course of the fibres of the optic nerves be- 
tween the retina and the cortex enables us to perfectly understand the 
different forms of hemianopsia due to lesions of the optic tracts. 

Thus homonymous lateral hemianopsia — that is to say, sensorial 
paralysis of the same half of each retina — has been observed in a great 
number of cases in which the lesion affected one of the optic tracts 
either directly or indirectly by the intermediation of neighboring or- 
gans. Now the theory given unqualifiedly requires that when a lesion 
destroys the optic tract of the left side, only the left half of each retina 
will be deranged in its position, and inversely if the lesion is situated 
on the right side. 

The resulting hemianopsia may be confined to one retina when a uni- 
lateral lesion only affects the most external fibres (homonymous hemi- 
anopsia) or the most internal (crossed hemianopsia) of one of the optic 
tracts. 

1 " De la deviation conjuguie des yeus.'" These de Paris, 1868. 



3±G 



DISEASES OF THE BRAIN". 



When a circumscribed lesion is situated in the anterior angle of 
the chiasma, so that its action is limited to the most internal of the 



Fig. 27. 




Diagram of the relation of the fields of vision, retina, and optic tracts. (Gowers.) 
E F, L F, right and left fields ; the asterisk is at the fixation-point. EK, LE, right and 
left retina ; the asterisk is at the macula lutea. I h, r h, left and right half of each 
retina, receiving rays from the opposite halves of the fields. EN, L N, right and 
left optic nerves. Ck, chiasma. E T, L T, right and left optic tracts ; below are the 
superimposed halves of the fields from which impressions pass by each optic tract. 

fibres- of the optic nerves, the result should be a temporal hemianopsia. 
In other words, in accordance with the theory, the visual trouble should 
be limited to the internal half of each retina. Saemisch has published 
a case of this kind, in which the diagnosis of the seat of the lesion 
was made during the life of the patient. 

Finally, in order that there should be a nasal hemianopsia — that is, 
that the visual trouble should be limited to the external half of each 
retina — it is necessary that a bilateral and symmetrical lesion should affect 
only the external part of each optic tract. This has been demonstrated 
by several cases ; among others, by those of Knapp, published in 1873. 



SYMPTOMATOLOGY OF CEREBEAL LESIONS. 



347 



V. 

LESIONS OF THE CEEEBEAL AND CEEEBELLAE PEDUNCLES. 

a. Crura Cerebri. 

The crura cerebri contain in their substance all the sensory and 
motor fibres which connect the periphery with the encephalic centres. 
Two parts, or strata, are to be distinguished in these organs, separated 
from each other 
by the substan- 
tia nigra. The 
inferior part con- 
tains the motor 
fibres which pass 
from the gray 
cortex of the 
hemisphere to 
the spinal gan- 
glia, and also 
fibres which ap- 
pear to connect 
the cerebrum 
with the cere- 
bellum. The su- 
perior part con- 
tains the sen- 
sory tract and 
some of the cra- 
nial nerve-cen- 
tres and their 
fibres. The di- 
rect motor-tract 
fibres are situ- 
ated in the mid- 




Diagram of section of crus. (Modified from Gowers.) 
L F, U F, lower and upper fillet or lemniscus. F E, formatio reticu- 
laris. CQ A, anterior corpora quadrigemina. Aq, aqueduct. 
Ill, nucleus of third nerve. P H, posterior horizontal fibres. 
Cp, brachium of post. corp. quad. E N, red nucleus. S N, sub- 
stantia nigra. CGI, internal geniculate body. T C, temporo- 
occipital cerebellar fibres. Py, pyramidal fibres. F, fibres from 
the face. A, fibres from the arm. L, fibres from the leg. F C, 
fronto-cerebellar fibres. C C, caudate cerebellar fibres, t, Inner 
fibres of crusta to tegmentum. 



die third of the crusta (Fig. 28), while in the sensory division the 
fibres transmitting muscular sense are to be found in the lemniscus, 
and those conducting other sensory impressions in the formatio reticu- 
laris. As the facial nerve does not decussate until the lower border 
of the pons is reached, a lesion in the pyramidal tract of one crus will 
produce hemiplegia on the opposite side of the body. Lower down, 
however, after the decussation of the facial nerves a unilateral lesion 
of the motor tract results in paralysis of the face on the side of the 
lesion and paralysis of the arm and leg on the opposite side. 

A lesion of the lemniscus is followed by unilateral ataxia on the 
opposite side. 

As the sensory division of the trigeminus decussates at the upper 



348 DISEASES OF TIIE BRAIN. 

border of the pons, a lesion of the formatio reticularis would result in 
anaesthesia of the face on the same side as the lesion and anaesthesia of 
the opposite arm and leg, but a lesion confined to the sensory area of 
one crus would induce hemi-anaesthesia on the opposite side of the 
body. 

Sometimes the third pair of nerves is affected, and then paralysis 
of the muscls of the eyeball supplied by it complicates the paralysis of 
the muscles of the opposite side. 

b. Cerebellar Peduncles. 

Curschmann has recently published the case of a tuberculous 
woman, who complained of vertigo and headache followed by con- 
vulsive seizures, at the end of which she fell on the right side. At 
the autopsy there was found a tuberculous meningitis, and a focus of 
softening on the right side involving the anterior and posterior cere- 
bellar peduncles. The same author has already proven by experi- 
ments that, if a cerebellar peduncle of one side be divided, the animal 
is at once seized with convulsions, and falls on the side corresponding 
to the lesion. 

More recently Coutry 1 has published the case of a man who pre- 
sented, as his only symptoms, obstinate vomiting and motor ataxia as 
regarded certain movements. These latter were jerking and sudden. 
At the autopsy of this man, who died of tubercular meningitis, there 
was found entire destruction of the left inferior cerebellar peduncle. 



CHAPTER XVIII. 

SYMPTOMATOLOGY OF CEREBELLAR DISEASES. 

The pathology of the cerebellum is as yet imperfectly understood. 
This is due, in the first place, to the insufiiciency of our knowledge of 
the functions of this organ, and, in the next, to th,e fact that very pro- 
found lesions may be situated in the cerebellum, and may even destroy 
it in great part, without causing the least functional disturbance ; while 
circumscribed lesions engender symptoms very variable in character, 
and due for the most part to compression of contiguous organs. 

These symptoms are, moreover, similar to those which result from 
lesions of the most varied of the nerve-centres. It is only the manner 
in which they are grouped together, and their greater or less frequency, 
which enables us to diagnosticate with some degree of assurance that 
the lesion from which they result is in reality situated in the cere- 
bellum. 

1 Comptcs rendus de la Societe de Biologie, seance du 5 Mai, 1877. 



SYMPTOMATOLOGY OF CEREBELLAR DISEASES. 



349 



Chief among them must be placed — 

(a.) Headache, vomiting, and vertigo ; phenomena that are ob- 
served very often in circumscribed lesions of the encephalon, whatever 
may be their seat, but which are met with more frequently in cases 
in which they are located in the cerebellum. 

(b.) Titubation ; a symptom which by some physiologists is as- 
signed to derangement of the coordinating faculty which, according 
to them, resides in the cerebellum. 

(c.) Motor excitations under the form of epileptic convulsions. 

(d.) Motor paralyses, which, however, generally consist of feeble- 
ness, and not complete loss of power in the limbs. 

(<?.) Sensorial troubles, such as those of sight and hearing. 

(/.) There are also to be noticed, in the course of cerebellar affec- 
tions, derangement of the faculty of speech, and paralyses of the face 
and of certain muscles of the eye ; symptoms which are due to the 
compression of contiguous organs, such as the cerebellar peduncles, 
the bulb, etc. [To this must be added that peculiar oscillatory mo- 
tion of the eyeballs, called nystagmus, a phenomenon rarely absent in 
cases of cerebellar disease. — W. A. H.] 

The following table shows at a glance the relative frequency of 
the several symptoms of cerebellar diseases. It is made up from cases 
adduced by some among the most eminent of those who have studied 
the subject : 



SYMPTOMS. 



Occipital headache 

Frontal " 

General " 

Vomiting " 

Troubles of motility 

Progressive feebleness of the muscles 

Uncertainty of gait 

Hemiplegia 

Paraplegia 

Strabismus 

Facial paralysis 

Predominance of action on one side of 

body 

Tremor 

Epileptiform convulsions 

Derangements of speech 

Amblyopia — amaurosis 



the 



Duehek, 
15 cases. 



10 



Ladane, 
56 cases. 



5 1 

is) 



54 
2 

16 
1 

2 



56 



Ollivier ar.d 

Leven, 76 

cases 



2 

25 

13 



41 



Luys, 100 
cases. 



25) 

6 [-50 
19) 

35 

45 
28 
16 

V 



5 

7 
12 
20 
18 



Some writers have attached a certain diagnostic importance to the 
absence in cerebellar diseases of anaesthesia and troubles of general 
sensibility. Nevertheless, Drozda, 1 of ninety-five cases of cerebellar 
affections collected by himself, found that in fifteen there were modi- 



Wiener med. Wochenschrift," 1876, p. 155 



350 DISEASES OF THE BRAIN. 

fixations of the general sensibility, not including headache among the 
number. 

On the other hand, the cerebellum having been for a long time con- 
sidered as the centre for the coordination of movements and of the mus- 
cular sense, the presence of motor incoordination and the abolition of 
the muscular sense have been regarded as the two pathognomonic signs 
of cerebellar lesions. Clinical observation has demonstrated the in- 
correctness of this view. Muscular sensibility has been found to re- 
main intact during the existence of lesions of the organ in question, 
and incoordination is a symptom peculiar to locomotor ataxia, the 
lesion of which exists in that portion of the spinal cord in which the 
radicles of the posterior nerve-roots are situated. In the cases of per- 
sons suffering from cerebellar disease the gait is vacillating and titubat- 
ing, like that of a drunken individual ; and the symptom is as well- 
marked when the patient walks with his eyes open as when he has 
them shut. There is not in these lesions that absence of harmonious 
muscular action that is observed in ataxics. 

Nevertheless, Huppert 1 has quite recently published a case of atro- 
phy of the cerebellum in an individual whose lower extremities were 
affected very much as are those of patients suffering from locomotor 
ataxia. To the uncertain and titubating gait are added often motor 
troubles similar to those which ensue in animals who have been sub- 
jected to experimental lesions of the cerebellum and its peduncular ex- 
pansions. There are irresistible impulsions forward or backward, and 
a like tendency to turn continually toward the same side; sometimes, 
also, the patients are unable to stand. 

Another characteristic of cerebellar lesions is the rapidity with 
which, in the great majority of cases, the ultimate phenomena super- 
vene. Contrary to the course of a great number of cerebral lesions, 
the beginning is insidious, and the fatal termination often supervenes 
in an unexpected and sudden manner. 

On the whole, we are led to diagnosticate a cerebellar lesion 
when we find united in the same patient a certain number of the fol- 
lowing phenomena : Occipital headache with nervous vomiting, ver- 
tigo, a staggering and uncertain gait, weakening of the muscular 
power without ataxia, amblyopia, amaurosis, and an irresistible ten- 
dency to turn over toward one side. [In this connection I may be ex- 
cused for quoting from a paper, 2 to which reference has already been 
made in other parts of the work, the following conclusions based on 
original experiments, and which have a bearing upon the subject of 
cerebellar disease : 

" 1. The consequences of removal of the cerebellum, if the ani- 

1 " Archiv fur Psychiatrie," B. vii., 18*77, p. 91. 

2 " The Physiology and Pathology of the Cerebellum," Quarterly Journal of Psycho* 
logical Medicine, January, 1869, p. 209. 



SYMPTOMATOLOGY OF CEREBELLAR DISEASES. 351 

mal survives the immediate effects of the operation, are not endur- 
ing. 

" 2. The entire removal of the cerebellum from some animals does 
not apparently interfere in the slightest degree, even for a moment, 
with the regularity and order of their movements. 

" 3. The disorder of movements, which results in birds and mam- 
mals immediately after injury of the cerebellum, is not due to any loss 
of coordinating power, but is the result of vertigo. 

" 4. The phenomena of cerebellar disease or injury, as exhibited in 
man, are not such as show any derangement of the coordinating power. 

" 5. In those diseases of which the chief phenomena relate to de- 
rangement of the coordinating power, the lesion is not in the cerebel- 
lum, and the symptoms are altogether different from those due to cere- 
bellar disease or injury." — W. A. H.] 

The principal lesions which may affect the cerebellum are tumors, 
hemorrhage, softening, and sclerosis, which latter sometimes terminates 
in atrophy of the organ. 



TUMOES OF THE CEREBELLUM. 

The cerebellum may be the seat of tumors of very different natures. 
Thus there are aneurisms or vascular tumors, parasitic tumors (cysticerci 
echinococci), cancerous tumors, tubercles, syphilitic gummata, sarco- 
mata, lipomata, etc. 

It is rarely the case that tumors are situated in the cerebellum with- 
out the neighboring parts being more or less affected by compression. 
Thus it is that the different instances which have been reported pre- 
sent variable groups of symptoms one from the other ; and in the future 
it will be necessary to separate with more exactness than has yet been 
done the phenomena which are the results of lesions of the cerebellum 
from those which are due to the compression of contiguous organs. 

Ordinarily those patients in whom, on post-mortem examination, a 
tumor has been found in the cerebellum, have presented, as an initial 
symptom, pain, generally in the occipital region, accompanied with 
nausea and obstinate vomiting. Sooner or later come troubles of mo- 
tility, consisting of titubation, the impossibility of standing erect, a 
tendency to roll over toward one side or the other, epileptiform con- 
vulsions, and general muscular weakness, which does not, however, or- 
dinarily reach the extent of actual paralysis. Statistics show that, in 
a large number of cases, individuals affected with cerebellar disease 
have exhibited some form of circumscribed paralysis, either of the hemi- 
plegic or paraplegic form. But such phenomena must, in general, be as- 
cribed to compression exercised on the motor fibres which pass through 



352 DISEASES OF THE BRAIN. 

the cerebral peduncles, the protuberance, and the bulb, by a tumor 
situated in the vicinity of the isthmus of the encephalon. Derange- 
ment of the faculty of speech and tremors of the tongue and lips have 
also been noticed in a large number of cases of tumor of the cerebel- 
lum ; and amblyopia, reaching to the point of extreme blindness, is also 
a very common symptom. M. Raymond 1 has reported a case of a 
woman, twenty-seven years old, at whose post-mortem examination a 
tumor was found, the size of a hen's egg, which was situated between 
the two lobes of the cerebellum, in such a position that it separated 
one from the other, so that the superior vermis was notably flattened by 
the pressure. The anterior extremity reached as far as the tubercula 
quadrigemina, which were also compressed. Relative to the position 
of the tumor M. Raymond says that it was such that the fourth 
ventricle was entirely obliterated. It is important, in view of the pa- 
thogeny of visual troubles, that the tubercula quadrigemina were 
entirely destroyed, and that the optic tracts were atrophied — facts 
which sufficiently account for the amblyopia. M. Raymond has added 
the abstracts of fifteen other cases of tumor of the cerebellum, accom- 
panied by papillary atrophy with amaurosis. 

From the comparison of these different cases, we are warranted in 
concluding that there is no definite connection between the seat of a 
tumor in the cerebellum and the development of morbid change in the 
optic nerves. We know, also, that atrophy of the optic nerves is met 
with in many other affections, spinal and cerebral, as well as cerebel- 
lar. Of sixty cases of tumors of the cerebellum, collected by Maca- 
biau, 2 forty were characterized by troubles of the eyesight. Generally 
these consisted of a more or less complete amaurosis, the result of 
atrophy of the optic nerve. In other cases the pupils were dilated or 
contracted, or there was deviation of the eyeballs to one side or the 
other. 

We therefore perceive that the symptomatology of tumors of the 
cerebellum is subject to great differences — a fact which renders the 
diagnosis very difficult ; and the fact must not be lost sight of, that a 
neoplasm of great size may be developed in the cerebellum, and not be 
manifested by any symptom during the life of the patient, only being 
brought to light in post-mortem examination. 

[A very interesting case of tumor of the cerebellum has recently 
been published by Prof. Diodato Borrelli, of the Royal University of 
Naples. In this instance there were numerous sarcomatous growths 
over the whole surface of the body, and after death similar growths 
were found in some of the viscera, the spinal cord, the cerebrum, and 
notably in the cerebellum. The compression exerted by the intra- 
cranial tumors had been sufficient to flatten the optic thalami and 

1 Gazette Medicate de Paris, 18*71, p. 371. 

3 "Des tumeurs du cervelet," Tliese de Paris, 1869. 



SYMPTOMATOLOGY OF CEREBELLAR DISEASES. 353 

corpora quadrigemina, and to push these latter out of their normal 
position. 

Two tumors were found in the cerebellum : one, on the left hemi- 
sphere, the size of a hen's egg ; the other, much smaller, was situated 
on the periphery of the right lobe. 

But it is not so much to the morbid anatomy as to the symptoms 
that I desire in this connection to call attention. These latter were 
observed with great care ; and though, of course, they were in part 
due to compression of neighboring organs, they do not differ in this 
respect from those likely to result in all cases of tumors of any part 
of the encephalon. 

The patient's countenance wore an expression of pain ; his eyes 
were from time to time seized with spasms, during which they turned 
in all directions ; his gait was titubating and uncertain, and he walked 
with his feet far apart, so as to increase his width of base ; there was 
intense vertigo ; the headache was agonizing, and was situated in the 
frontal and vertical regions, but even more decidedly in the occipital 
region ; vomiting, which was persistent and unamenable to treatment, 
and a tormenting pruritus, were also present ; and there were tonic 
spasms of the muscles of the neck, by which the head was strongly 
rotated to the right. 

The visual power was diminished, though not equally, in both eyes, 
and the hearing was similarly affected. The other special senses were 
not deranged, and the general sensibility of the body w T as apparently 
intact. Neither was there any notable impairment of muscular power, 
though the lower extremities were somewhat more affected in this 
way than the upper. As to the mental condition, at first sight it ap- 
peared as though it were normal, but careful observation showed that 
the memory was weakened. 1 — W. A. H.] 

II. 

HEMORRHAGES OF THE CEREBELLUM. 

M. Hillairet, who was the first to study haemorrhages of the cere- 
bellum by separating them from those occurring in other parts of the 
body, distinguishes two forms — the one sudden, the other chronic and 
of slow progress. 

In the sudden form the patient is struck with an apoplectic shock, 
and dies comatose at the end of a short time. In the slow form the 
intelligence remains intact, the patient complains of headache, gener- 
ally in the occipital region, and vomiting is very frequent. The other 

1 Dr. Borrelli follows his account of this interesting case with a very full bibliography 
of the literature of cerebellar tumors, and a thoroughly well-digested and critical essay 
upon the subject. 
24 



354 DISEASES OF THE BRAIN. 

symptoms consist of a vertiginous, titubating gait, and a general weak- 
ness of the limbs, difficulties of speech, and troubles of vision. Hemi- 
plegia, which has been considered a common symptom of lesion of 
the cerebellar substance (Hillairet), should be regarded, according to 
M. Vulpian, as an effect of the compression exercised by hemorrhagic 
centres on the motor fasciculi of the isthmus of the encephalon. 

On the whole, the symptoms of cerebellar haemorrhage are the 
same as are observed in tumors of this organ, with the exception that 
their evolution is much more rapid. In fact, even in the slow form of 
the disorder, it is rare that the patient survives more than a few days. 



III. 

ATROPHY OP THE CEREBELLUM. 

Atrophy of the cerebellum, when it is not congenital, is generally 
consecutive to sclerosis of that organ. It can not be recognized by any 
positive symptom. Sometimes it is met with in epileptics. M. Du- 
guet has reported three examples of this condition. In a case of very 
pronounced atrophy of the cerebellum, in a young man twenty-two 
years of age, Max Huppert 1 has noticed during life epileptiform con- 
vulsions, choreiform agitation of the muscles, with diminution of mus- 
cular force, difficulty of standing erect, titubation during walking, and 
trouble of speech. The limbs, which were not paralyzed, were never- 
theless affected with incoordination similar to the same symptom as 
observed in ataxics. 

A case of what is probably sclerosis and atrophy of the cerebel- 
lum was for several years under my observation, and was presented 
by me before the American Neurological Association at its meeting in 
June, 1877. 2 

The patient, a boy about four years of age, was brought to my 
clinique at the University Medical College in January, 1876. He was 
apparently in good health, was well grown for his age, and had not 
been subject to any exhausting disease. As he sat upon a chair, he 
exhibited no indications of paralysis, spasm, or incoordination. He 
moved both legs well and with normal force, and could use either 
hand in the ordinary way. But it was impossible for him to assume 
the erect posture, and when he attempted to do so he stood in a pecul- 
iar, one-sided, stooping position, the left arm being strongly flexed 
against the side of the chest, while the right was thrown out behind 
him. He could not maintain himself on his feet without support. 

1 " Archiv fur Psychiatrie und Nervenkrankheiten," B. iii., p. 98. 

2 " On a Hitherto Undescribed Form of Muscular Incoordination," " Transactions of 
the American Neurological Association, 187'7." 



SYMPTOMATOLOGY OF CEREBELLAR DISEASES. 



355 



Fia. 29. 



The attitude is shown in the accompanying woodcut, Fig. 29, taken 
from a photograph. 

In walking he was able to direct his steps with a certain amount 
of precision, but yet not to a normal extent. He appeared also to 
have more difficulty in arresting his movements, and was accordingly 
apt to come up violently against obstacles which were in his way. 
His gait was rather a run than a walk, and he often fell. In bring- 
ing the case before the class I expressed the provisional opinion that it 
was one of chorea paralytica, but further 
examination, and the inefficacy of all treat- 
ment, soon caused me to change this view. 

In May he came under the charge of a 
surgeon, who circumcised him, under the 
impression that the case was one of reflex 
incoordination. It is scarcely necessary to 
say that the operation was unsuccessful. 
When he appeared before the Association, 
in June, there had been a gradual advance 
in the intensity of his symptoms. Yet, 
notwithstanding the marked incoordination, 
there was no paralysis, no derangement of 
sensibility, no bladder disturbance, no 
spasm, no diminution of electric excitabil- 
ity of the muscles, and none of the peculiar 
symptoms indicative of sclerosis of any 
part of the cord. 

After this there was a short intermission 
in his symptoms, and his father thought 
he was recovering. He wrote me to that 
effect, September 7th, no medicine having 
been taken. But soon afterward he again 

relapsed, and his condition gradually became worse. When I last saw 
him, about a year ago, there were nystagmus and a total inability to 
stand. When he tried to do so, he bent over till his head touched the 
floor, and thus he remained, apparently endeavoring to stand on his 
head. When he wished to go anywhere in the room, he lay down on 
the floor and rolled toward it, turning over toward the left always. 
About this time Dr. J. S. Jewell, of Chicago, saw the patient. Con- 
tinued examination and study of this very interesting case lead me to 
the opinion that it is one of sclerosis and atrophy of the cerebellum. 

The subject of the diagnosis of diseases of the brain cannot be 
passed over without a reference to the masterly work of Nothnagel 1 
on the subject, even if that reference does not go further than citing 




Topiscbe Diagnostik der Gehirnkrankheiten ; eine klinische Studie," Berlin, 18*79. 



356 DISEASES OF THE BRAIN. 

the conclusions at which he arrives, modified by the light that more 
recent investigation has thrown on the subject. 

Cerebellum. 

" 1. Diseases of the cerebellum may remain completely latent, and 
thus be incapable of being diagnosticated. This is generally the case 
with destructive lesions situated in one hemisphere. 

" 2. Lesions of slight extent may, on the other hand, present a 
very variable and complicated appearance. 

" 3. The most characteristic symptoms of cerebellar affections are 
incoordination, a titubating gait, and intense vertigo. These symp- 
toms are, however, met with in other brain-diseases, and cannot, there- 
fore, be considered pathognomonic. It is by a consideration of all the 
phenomena, positive and negative, that the diagnosis of cerebellar dis- 
eases is to be made. 

"4. Cerebellar staggering always denotes the involvement of the 
middle lobe, whether this be the primary situation of the lesion or an 
implication (functional also) through pressure. 

" 5. At the same time, incoordination and vertigo may be absent 
in diseases of the cerebellum situated mainly in the hemispheres, as is 
also the case sometimes with tumors the seat of which is the vermis. 
If in such a case we feel justified on other grounds in suspecting the 
existence of a lesion in the posterior encephalic region below the ten- 
torium, we can never, with any approach to certainty, diagnosticate 
the existence of either primary or secondary diseases of the cerebel- 
lum. Its implication under such circumstances is possible, but is by 
no means a matter of certainty. 

" 6. In addition to the symptoms given under section 3, there are 
some others which can be considered as indicating the existence of a 
disturbance of the functions of the cerebellum, and hence the presence 
of lesions of this organ. Perhaps certain derangements of speech 
(anarthia) in cases of extensive atrophy of the cerebellum may be so 
regarded, but yet there is no surety on the subject. 

" 7. Yomiting, when constant and severe, may in some cases sup- 
port the diagnosis of a cerebellar disease, but it is not conclusive of 
such a condition, for it is often an accompaniment of other encephalic 
affections. It is lacking in all cases of destructive lesions, and is not 
a constancy in those due to pressure from diseased contiguous organs. 

" 8. The like is true also of amblyopia and amaurosis, and of 
choked disk and optic neuro-retinitis. 

" 9. Headache is likewise only met with in cases of pressure from 
diseased continuous organs. Its fixed situation in the posterior cra- 
nial region may in some cases indicate the existence of a cerebellar 
disease, but it is no more pathognomonic of such an affection than its 
presence in the frontal region would indicate a healthy cerebellum. 



SYMPTOMATOLOGY OF ENCEPHALIC DISEASES. 357 

" 10. The most diverse derangements of the motor and sensory- 
cerebral and spinal nerves may exist in conjunction with cerebellar 
disease, but only in cases of lesions due to pressure. They are not, 
therefore, in instances of disease of the cerebellum, of any diagnostic 
importance. On the contrary, they are very apt to lead to errors of 
diagnosis. Still, however, if we can, out of all the symptoms, select 
some one of derangement of motor or sensory nerves, we may find 
important indications toward the exact localization of the lesion. 
Thus, for instance, paralysis of the whole of the right facial nerve 
indicates the existence of a tumor on the corresponding side, and de- 
cided hemiplegia its seat on the basilar surface. Generally, how- 
ever, we must be careful not to draw definite conclusions in this 
respect. 

"11. Psychical derangements are absent. Only under the general 
conditions which exist in all brain-lesions, whatever their situation, 
are we apt to meet with them in affections of the cerebellum. Never- 
theless, they are probably ordinary phenomena in general atrophy of 
the organ." 

Crura Cerebelli. 

" 1. Stationary destroying lesions of the crus-cerebelli, producing 
complete destruction of the same, cause no characteristic symptoms of 
diagnostic value. 

" 2. Irritative lesions alone produce such symptoms, and then only 
when the connection of the crus with the cerebellum is not interfered 
with. Haemorrhages only produce symptoms in the beginning. 

" 3. These symptoms consist in forced positions of the trunk, head, 
and eyes, rotatory motions on the long axis of the body, and in vertigo, 
with the inclination to fall to one side. 

" 4. Of the foregoing symptoms, the only ones which are character- 
istic are the position of the eyes and rotatory movements of the body 
observed by Xonat, as all the rest, so far as they have been clinically 
noticed, have been recognized as being due also to other localized 
lesions. 

" 5. On the contrary, the turning of the body, together with a 
like movement of the head and eyes, indicates the existence of a crus- 
cerebellar lesion. 

" 6. The direction of these movements is sometimes toward the 
healthy side and sometimes toward the diseased side, but as yet the 
cause of these differences is not known. 

" 7. Whether or not disturbances of coordination and ataxia result 
from lesions of the crus-cerebelli, is not yet ascertained. 

" 8. The foregoing remarks refer entirely to the median crus to the 
pons. There is nothing to be said relative to the anterior and poste- 
rior crura." 



358 DISEASES OF THE BRAIN. 

Pons. 

1. The form of motor paralysis resulting from a lesion of one pyra- 
midal tract in the pons depends upon the level at which the lesion oc- 
curs. In the upper third of the pons each pyramidal tract containsi all 
the fibres which supply motor power to the muscles on the opposite 
side of the body. Hence a lesion involving the motor tract in the 
upper third of the pons would produce hemiplegia on the opposite side. 

2. In the middle third of the pons the facial nerve decussates while 
the motor fibres do not. A lesion below this level, therefore, would be 
followed by crossed paralysis — that is, by paralysis of the face on the 
same side as the lesion, and paralysis of the arm and leg on the oppo- 
site side. 

3. In the lower third of the pons the hypoglossal nerve decussates. 
A lesion at this level can be distinguished from a lesion of the middle 
third by the addition of the symptom of paralysis of one side of the 
tongue. The paralysis of the tongue would, of course, be on the same 
side as the facial paralysis. This would cause a deviation of the 
tongue toward the side of the lesion. 

4. The sensory tract passes up to the cerebral cortex through the 
formatio reticularis. A lesion of this region in the upper third of the 
pons produces anaesthesia on the opposite side of the body. In the 
middle third the sensory division of the trigeminus decussates ; hence 
a lesion in the lower two thirds of the pons results in crossed anaes- 
thesia — that is, anaesthesia of the face on the same side as the lesion, 
and loss of sensibility in the opposite arm and leg. 

5. The tract for the transmission of muscular sense lies in the lem- 
niscus in the pons. A lesion involving the lemniscus will be fol- 
lowed by ataxia of the arm and leg on the opposite side of the body. 

6. The motor nuclei and nerve roots which may be injured by lesions 
in the pons are those of the trigeminus, the abducens, the facial, the 
glossopharyngeal, the pneumogastric, the spinal accessory, and the 
hypoglossal. Irritative lesions are followed by spasm of the muscles 
which these nuclei supply, while destructive lesions result in paralysis. 

7. The sensory nuclei situated in the pons are those of the trigemi- 
nus and the auditory. Destruction of the trigeminus, sensory nucleus, 
or its root results in anaesthesia of the face on the same side as the lesion. 

8. Destruction of the ventricular nucleus of the auditory nerve 
is followed by deafness on the side of the lesion, and disease of the 
extra- ventricular nucleus produces rotatory movements, or a tendency 
to turn to one side. 

9. Convulsions frequently follow any sudden lesion in the pons. 

Medulla Oblongata. 

1. The diagnosis of lesions of the medulla oblongata can not always 
be made with certainty. 



SYMPTOMATOLOGY OF ENCEPHALIC DISEASES. 



359 



Fig. 30. 



2. Lesions of the formatio reticularis in the medulla, as in the pons, 
produce anaesthesia of the opposite side of the body and of the same 
side of the face. Lesions of the inter-olivary tract result in a loss of 
the muscular sense on the opposite side of the body. 

3. Lesions of one pyramidal tract are followed by paralysis of the 
opposite arm and leg, and, as the nerve root of the hypoglossal lies so 
close to the pyramid, there may also be paralysis of the tongue on 
the same side as 

the lesion. The 
face is not para- 
lyzed from a lesion 
confined to the 
medulla, as the 
facial nerve and 
nucleus are situ- 
ated higher up in 
the anterior third 
of the pons. 

4. The nuclei 
and nerve roots 
affected by lesions 
in the medulla are 
those of the audi- 
tory, glosso-pha- 
ryngeal, pneumo- 
gastric, spinal ac- 
cessory, and the 
hypoglossal. 

Injury of the 
ventricular nucle- 
us, or of its fibre, 







JfetcrTract 



Section through the medulla. (Slightly modified from Edinger.) 



side as the lesion. 



the striae acusticae, results in deafness on the same 
Injury of the extra-ventricular nucleus gives rise 
to rotatory movements and inability to retain an equilibrium. 

Lesions of the glossopharyngeal nucleus and nerve are of infre- 
quent occurrence, but when present produce loss of taste on the same 
side as the lesion. 

Lesions of the spinal accessory and pneumogastric nuclei give rise 
to paralysis of articulation and respiration on the one hand, and to 
huskiness of voice, difficulty in breathing, and feeble and irregular 
heart's action on the other ; but these two nuclei are so closely related 
topographically that any lesion affecting one of them usually affects 
the other also. 

Destruction of the hypoglossal nucleus or nerve gives rise to paral- 
ysis of the tongue on the same side as the lesion. An irritative lesion, 
however, causes spasmodic twitchings. 

5. Vaso-motor symptoms, such as flushing of the surface and sensa- 



360 DISEASES OF THE BRAIN. 

tions of heat, and of abnormal sweating, are, according to Starr, 1 
frequently observed following lesions of the upper half of the medulla. 

Corpora Quadrigemina. 

" 1. The diagnosis of lesions of the corpora quadrigemina is very 
difficult and uncertain, for the reason that the symptoms are some- 
times exceedingly ambiguous and at others scarcely noticeable. 

" 2. From a consideration of the results of our present experience, 
it appears that the symptoms due to lesion of. the anterior and posterior 
pair respectively are different. The implication of the anterior pair is 
accompanied with diminution of the sense of sight, or even blindness. 
This symptom is, however, of very ambiguous character, and must not 
be necessarily referred to lesion of the corpora quadrigemina, since 
lesions in this region are liable to affect the optic tract either directly or 
by pressure. The diagnostic value of amaurosis appears to us as of most 
importance under the following circumstances : when it is sudden and 
acute, with non-mobility of the pupils, accompanied with other symp- 
toms of lesion of the brain and with negative ophthalmoscopic results. 

" 3. Lesions of the posterior pair are accompanied, but not always, 
with paralysis or paresis of the oculo-motor nerve. Its existence is not, 
however, any more than its absence, an infallible mark for diagnosis. 

" 4. Great importance is to be attached to the character and ap- 
pearance of the oculo-motor disturbance — a unilateral paralysis may 
exist from a bilateral lesion, and, when unaccompanied with alternate 
paralysis of the extremities, points to the tubercula quadrigemina as 
the organs involved. 

" 5. This bilateral implication of the motores oculorum appears to 
be sometimes due to a unilateral lesion of the tubercula quadrigemina. 

" 6. Relative to the state of the pupil nothing exact is known. It 
appears, however, that lesion of the anterior pair arrests its reactions. 

" 7. From lesions of the posterior pair it appears that disturbances 
of equilibrium and coordination may result, similar to those due to cere- 
bellar disorders." 

Thalami Optici. 

" 1. Relative to the majority of the symptoms regarded as being 
due to lesions of the thalamus, it is very doubtful if they have a 
direct relation to this organ, or only occur indirectly through implica- 
tion of neighboring cerebral parts. Other manifestations, really the 
result of thalamic lesion, are of uncertain import, or they occur also 
from disease of other encephalic organs. 

" 2. From which it follows that a certain diagnosis of an isolated 
thalamic lesion is, in the present state of our knowledge, in the ma- 
jority of cases impossible. Only under a very favorable combination 
of circumstances is it possible to arrive at a definite conclusion. 
1 Starr, Journ. New. and Ment. Lis., July, 1884. 



SYMPTOMATOLOGY OF ENCEPHALIC DISEASES. 361 

" 3. Motor paralysis cannot, in our opinion, support the idea of a 
possible thalamic lesion. On the contrary, when paralysis exists we 
must suppose other parts to be involved, even if the thalamus is the 
principal seat of the lesion. 

" 4. The like is true of sensory paralysis. If, through the rela- 
tions which exist between injuries of the part of the internal capsule 
near the thalamus, and sensibility, it is sometimes concluded that the 
lesion is situated near the thalamus or in it (in such a manner that the 
internal capsule is also implicated), we even then are not warranted in 
diagnosticating the existence of a thalamic lesion. 

" 5. That which is said under section 4 is true also of vaso-motor 
tracts. 

u 6. Disturbances of sight may occur through lesion of the poste- 
rior third of the thalamus. This is invariably homonymous hemianop- 
sia. But such visual disturbances do not indicate with any degree of 
sureness the existence of thalamic lesions, as they may occur with other 
localized brain-diseases, such as those of the occipital lobes, corpora 
quadrigemina, and optic tracts. 

" 7. A peculiar series of irritative motor disturbances, such as hemi- 
chorea, athetosis, and unilateral tremor, are possibly due to thalamic 
lesion. Nevertheless, if this fact were definitely established, these 
phenomena would, even in undoubted cases of thalamic disease, be of 
little value diagnostically, as they may occur when the lesion has a 
very different location. 

" 8. That a diminution or increase of reflex excitability indicates 
disease of the thalamus is incorrect. 

" 9. Possibly, disturbances of the muscular sense, and — 

" 10. Disorders of psycho-motor reflex actions, are indications of 
thalamic lesions. Further observations and investigations are, how- 
ever, necessary on these points. 

" Taking everything into consideration, in the present state of our 
knowledge, a lesion of the optic thalamus may, perhaps, under a par- 
ticularly favorable combination of circumstances, be diagnosticated, 
if the conditions stated under sections 6, 7, 9, and 10 be present, but 
even then this cannot be done with certainty." 

Corpora Striata. 

" 1. Destroying lesions of the corpus striatum may produce crossed 
motor, sensory, and vaso-motor paralyses. 

" 2. If the lesion be not too small, motor hemiplegia is uniformly 
present. 

" 3. This hemiplegia may gradually disappear if the lenticular or 
caudate nucleus be alone involved. It remains, however, if the inter- 
nal capsule be involved, whether alone or in conjunction with the gray 
nuclei. In these permanent paralyses — that is to say, those due to 



362 DISEASES OF THE BRAIN. 

lesions of the internal capsule — there is often subsequently secondary 
muscular contraction. 

" 4. The motor hemiplegia resulting from stationary destructive 
lesions affects constantly both extremities of one side and the inferior 
branch of the facial nerve. Usually the muscles of the trunk are also 
rendered paretic. The hypoglossal is either not at all or only in the 
beginning affected. Its implication is seldom permanent. 

" In rare cases the extremities or the facial are alone involved. 

" 5. The symptoms of lesion of the lenticular nucleus are not of 
such a character as to admit of their distinction from those due to 
lesion of the caudate nucleus. 

" 6. Motor paralysis is the sole symptom, if the lesion is situated 
only in the anterior third of the corpus striatum in the region sup- 
plied by the lenticular striated artery. 

" 7. In some cases hemi-ansesthesia is an accompaniment of the 
hemiplegia. This is characterized by the fact that along with the 
cutaneous anesthesia the nerves of special sense — sight, hearing, taste, 
and smell — on the corresponding side are affected ; still, these latter 
are not necessary features in hemi-anaesthesia due to lesions of the 
corpus striatum, as the condition is generally confined to the skin. 

" 8. The hemi-anaesthesia shows the implication of the most pos- 
terior part of the internal capsule with the contiguous part of the 
corona radiata ; still, lesions may exist in the posterior part of the 
internal capsule between the optic thalamus and the lenticular nucleus 
without the production of anaesthesia. 

" 9. Generally the hemiplegia and the hemi-ansesthesia exist to- 
gether. It is only occasionally that the first disappears and that the 
latter remains. 

" 10. Occasionally disturbances in the functions of vaso-motor in- 
nervation — increased temperature, redness, etc. — occur in the paralyzed 
parts. These indicate the implication of the posterior portion of the 
internal capsule. 

" 11. Hemichorea, hemiathetosis, and other forms of hemi-mobile 
spasm often occur in conjunction with lesions of the corpus striatum. 

Centrum Ovale. 

In regard to lesions of the white substance of the brain — constitut- 
ing the centrum, no very definite conclusions are reached by Nothna- 
gel. Thus stationary destroying lesions of occipital, spheroidal, and 
anterior and middle frontal portions, give rise to no well-marked 
symptoms. The same is true of pressure-lesions. 

The most important symptom is that resulting from lesions of the 
anterior and posterior central regions — motor paralysis of the opposite 
side, like that caused by lesions of the corpus striatum or cortex. 

Aphasia is a probable symptom of lesion of the white substance of 
the foot of the third frontal convolution. 



SYMPTOMATOLOGY OF ENCEPHALIC DISEASES. 363 

t 
The Cortex. 

" 1. Disease of the surface of the brain — that is, of the gray sub- 
stance and the immediately contiguous white substance — produces in 
one group of cases decided symptoms ; in another they are without 
symptoms, remaining latent. 

" 2. Psychical derangements indicate, in general, disease of the su- 
perfices of the brain (Hirnoberflache), but exact localization cannot as 
vet be made. 

"3. Motor aphasia, or the inability to remember how to make the 
muscular movements necessary for pronouncing words, is often due to 
disease of the cortex in the region of the posterior extremity of the 
inferior frontal convolution ; but it must be remembered that disease 
of the conducting fibres from this region also produce motor aphasia. 
Lesions of this part of the cortex are also followed by amnesic aphasia 
— that is, by inability to remember words. 

"4. Word-blindness, or the loss of the power of remembering the 
appearance of written or printed words, is due to disease of the cortex 
of the occipital lobes and perhaps of the angular gyrus. 

"5. Word-deafness, or the inability to remember the sound of 
words, is caused by a lesion of the cortex of the anterior half of the 
superior and middle temporal convolutions. 

" 6. Paraphasia, or the inability of an individual to speak coherent- 
ly, is, according to Wernicke, produced by lesions of the island of Reil, 
or by a lesion of any part of the conducting tract between the cortical 
word centre at the base of the third inferior frontal convolution and 
the word-hearing centre in the temporal convolutions. 

"7. Hemianopsia does not of itself indicate the existence of a cor- 
tical lesion. At best we can only suspect such, and then probably 
in the occipital lobe, when the condition in question is developed sud- 
denly, as a single symptom, and with entirely negative ophthalmo- 
scopical phenomena — perhaps after an apoplectic attack. 

"8. Unilateral disturbances of vision may occur as the consequence 
of lesions of the superficies of the brain. Hitherto they have only been 
observed with diffused cortical lesions, such as progressive paralysis and 
cysticerci. As to their importance in locative diagnosis, nothing of any 
positiveness can be said. 

" 9. Sensory disturbances of the skin are sometimes caused by 
lesions of the cortex. According to Dana, the sensory cortical centres 
are in the same locality as the motor cortical centres, but are more 
diffuse, and sensory symptoms resulting from disease of this area are 
more liable to be transient than when they are the result of lesions 
elsewhere. 

" 10. Unilateral disturbance of the muscular sense, when it appears 
by itself without attendant phenomena, perhaps indicates the existence 
of a lesion of the parietal lobes, but it must not be forgotten that a 



364 DISEASES OF THE BRAIN. 

unilateral lesion of the lemniscus in the pons and medulla may produce 
the same symptom. 

" 11. Motor derangements occur in conjunction with cortical lesions, 
and under certain circumstances may by their character enlighten us in 
regard to the latter. 

" 12. Sometimes the paralysis appears as a simple hemiplegia, such 
as is ordinarily the result of a lesion of the motor division of the in- 
ternal capsule, with or without secondary contractions in the paralyzed 
extremities. In this case the diagnosis is impossible. Nevertheless, 
the belief that a cortical lesion existed would be strengthened if there 
were also permanent aphasia. 

" If, in connection with paralysis of the extremities and the facial 
and the hypoglossal nerves, there is ptosis, it is probable that a corti- 
cal lesion exists. 

" On the contrary, decided disturbances of sensibility occurring in 
conjunction with motor hemiplegia indicate either that the lesion is 
not cortical, or that, if it is, it involves the cortex to a wide extent. 

" 13. Relatively, paralyses due to lesions of the cortex are often 
monoplegias, partial hemiplegias, isolated paralyses of the facial, the 
hypoglossal, and the nerves of the arm (rarely of the leg), or of the 
arm and leg, or arm and face. 

" 14. These monoplegias, their intracerebral origin being first de- 
termined, indicate, not with absolute certainty but with great proba- 
bility, a cortical lesion. 

" 15. The character and development of these monoplegias alone 
are of no consequence as indicating a cortical lesion. 

" 16. On the other hand, certain kinds of motor irritative phenom- 
ena are of great value in the diagnosis of cortical lesions. 

" 17. These appear sometimes as partial convulsions of individual 
muscles, and occur either as the consequences of haemorrhage or soften- 
ing, or by the development of a tumor, and which subsequently are fol- 
lowed by paralysis of the affected muscles. In such cases we may with 
great probability, almost with certainty, suspect a lesion of the cortex. 

" Or partial clonic convulsions make their appearance in the already 
paralyzed region. In such cases, judging by our present experience, 
a lesion of the cortex exists. 

" 18. In other cases the motor phenomena are those of a general 
epileptiform attack, and with the peculiarity that the typical recurring 
spasm always begins in the same group of muscles in an extremity or 
half of the face. This form of convulsion is always developed after 
an existent paralysis. It may be regarded as a probable symptom of 
lesion of the cortex. 

" 19. The existence of motor symptoms from lesion of the cortex 
indicates that the seat of the morbid cause is in the anterior central 
and posterior central convolutions and the paracentral lobule." 



SECTION II. 
DISEASES OF THE SPIRAL COED 



CHAPTER I. 

SPINAL CONGESTION. 



Though congestion of the spinal cord, like that of the brain, is of 
two kinds, active and passive, yet the symptoms and general course of 
the two varieties are so generally alike, that nothing would be gained 
by considering them separately. 

Symptoms. — The symptoms of spinal congestion are referable to the 
cord and to those parts of the body below the seat of the lesion. The 
most prominent local phenomenon is pain, which is rarely acute, but is 
described as a dull, aching sensation similar to that experienced in the 
back after severe and long-continued muscular exertion in a stooping 
attitude. This pain is increased by the recumbent posture and by stand- 
ing, if the lower part of the cord be its seat; but pressure, if steadily 
applied, does not augment it. A sudden blow or a shock, such as that 
produced by making a false step, aggravates it to a considerable ex- 
tent. 

A sensation of heat is occasionally experienced in the cord, which is 
not unpleasant, and which is not affected by pressure. 

With the local symptoms there are others still more notable per- 
ceived in the parts of the body below the seat of the disease. Thus, if 
as is very generally the case, the lesion be situated in the dorsal or lum- 
bar region, there are disturbances of sensibility and motility in the 
lower extremities. The various sensations indicating anaesthesia are 
present, and are usually first experienced in the skin covering the under 
surface of the toes. Formication, " pins and needles," tingling, and a 
feeling as if the toes are swollen, are noticed. It is rarely the case 
that the anaesthesia is complete. Its extent and exact situation may 
be accurately determined by the aesthesiometer. 



306 DISEASES OF THE SPINAL CORD. 

Sometimes there is hyperesthesia, and occasionally both conditions 
coexist. The extent of either may be definitely measured with the 
aesthesiometer. Shooting- pains in the limbs and along the course of 
the nerves coming from the diseased part of the cord are now and then 
present, but they are not a prominent feature in simple congestion. 

A sensation of constriction is at times complained of, and is referred 
to the body or one or both of the limbs. It is compared to the feeling 
which would be produced by a tight cord, or encasement in an unyield- 
ing garment. It is rare in uncomplicated spinal congestion. Accord- 
ing to the situation of the lesion, there are pains either in the abdomen, 
chest, or both, and there may be dyspnoea and palpitation of the heart. 
In three cases under my care, the difficulty of breathing and irregula-r 
cardiac action were prominent features. Similar cases are cited by 
Ollivier ' (d' Angers). The temperature of the parts of the body below 
the lesion is always reduced, from the fact that the vaso-motor nerves 
are involved. 

Erections of the penis are common, especially after the patient has 
been in the recumbent position for some time. 

The most striking phenomena of spinal congestion are those con- 
nected with the alterations of motility. Paraplegia is always present 
to some extent, though it is rarely complete. Thus the patient, though 
unable to walk, can generally move the legs when sitting down or lying 
in bed. Twitchings of the muscles are occasionally present, but not 
often to a severe degree. 

The loss in the power of motion, like the alterations in sensibility, 
is only present in those parts of the body situated below the diseased 
parts of the cord. The bladder is very generally affected, either in its 
own muscular tissue or in its sphincter. In the first case, there is a dif- 
ficulty of expelling the urine, owing to loss of expulsive power, and this 
is aggravated by paralysis of the abdominal muscles, or there is incon- 
tinence of urine from paralysis of the sphincter. Both conditions may 
coexist, and then, when a sufficient quantity of urine has accumulated in 
the bladder, it dribbles away. In such a condition, the bladder is never 
entirely empty, and the urine is passed alkaline and >f etid. 

The sphincter of the rectum is sometimes involved, producing in- 
voluntary evacuation of the faeces, but obstinate constipation from 
paralysis of the abdominal muscles, and consequent loss of expulsive 
power, are much more common. Reflex excitability is, according to 
my experience, invariably lessened, and is sometimes entirely abolished. 

The electro-muscular contractility of the paralyzed muscles is always 
more or less diminished, though not to the same extent as in some 
other affections of the cord. As a general rule, the farther the muscle 
is from the centre the less is its electro-muscular contractility. 

lu Traite des maladies de la moeRe epiniere," troisierae Edition, Paris, 1837, tome 
iii., pp. 1-137. 



SPINAL CONGESTION. 367 

The tendency of spinal congestion is to extend itself and eventually 
to involve the whole cord. In the active form of the disease, this pro- 
cess often takes place with great rapidity, and the symptoms generally 
are more pronounced and succeed each other with more promptness. 
The phenomena of spinal congestion are always rendered more decided 
by the patient's assuming the recumbent posture. He is hence more 
paralyzed in the morning before rising from bed than in the evening 
before he retires. This is due to the fact that the position in question, 
especially if he lies on his back, allows the spinal blood-vessels to be- 
come more readily distended. It is the same thing as regards the cord, 
that keeping the head in a dependent position would be as regards the 
brain. 

Bed-sores are not common. Radcliffe * seems to assert that they 
are never met with. Brown-Sequard 2 says an ulceration upon the 
sacrum or nates is not rare in this affection. Ollivier 3 does not men- 
tion them in his account of the disease. Of the large number of cases 
of spinal, congestion that have come under my observation, bed-sores 
occurred in but two, and in these there was reason to believe they were 
not the special result of the lesion of the cord. 

According as the antero-lateral or posterior columns are mainly 
affected, the symptoms of spinal congestion differ. Thus, in the former 
case, the phenomena are chiefly manifested as regards motility, in the 
latter as regards sensibility. Generally both sets of columns are in- 
volved. In spinal anaemia, as we shall presently see, this is not the 
case. 

Causes. — The most common cause of spinal congestion, according to 
my experience, is exposure to intense cold. Fevers appear to be next 
in frequency, especially those of malarious origin, and the excessive 
use of alcoholic liquors probably comes next as a causative influence. 

Venereal excesses, and maintaining the erect posture for a long time, 
were the obvious cause in several cases. This last influence was very 
well marked in the case of an eminent lawyer of this city, who became 
suddenly affected with spinal congestion after making a speech of sev- 
eral hours' duration. The suppression of a customary discharge, such 
as the menstrual flow or a hemorrhoidal bleeding, is likewise liable to 
induce congestion of the cord. I have recently treated two cases, in 
which the congestion of the cord followed the cold stage of intermittent 
fever ; and it is occasionally the result of blows and falls. I have seen 
several cases which were due to railway injuries. 

In one of these the patient, an elderly gentleman, was violently 
thrown to the floor of a railway-car in consequence of a collision with a 
stationary train in front. At first, there were nausea, vomiting, slow 

1 Lectures on the "Diagnosis and Treatment of the Principal Forms of Paralysis of th6 
Lower Extremities," Philadelphia, 1861, p. 69. 

8 Op. cit. 3 Reynolds's " System of Medicine," vol. ii., p. 622. 



368 DISEASES OF THE SPINAL CORD. 

and feeble pulse, and very great nervous prostration — in fact, all the 
more prominent symptoms of shock. The injured man revived after 
the administration of stimulants, and was partly enabled to walk to an 
hotel near by. On the following day, however, pain was experienced 
in the lower dorsal region, and difficulty was experienced in moving 
the legs. Sensibility was impaired in the lower extremities. The 
bladder was partially paralyzed, and in consequence the urine was 
drawn off with the catheter. From this time his condition became 
worse, till at last, sensibility was entirely abolished in both lower 
extremities, and the power of motion was altogether lost. The bladder 
never became entirely paralyzed. The sphincters both of the bladder 
and rectum remained unaffected. When I saw him, three months after 
the reception of the injury, he was incapable of feeling the prick of a 
pin in any part of his body below the first lumbar vertebra, and could 
not move a single muscle of the lower extremities. There were no bed- 
sores, and the condition of the limbs was not impaired. Electro- 
muscular contractility, though greatly lessened, was not completely 
lost. A two-cell galvano-faradic battery, when used with its full power, 
failed to produce any contraction; but all the muscles responded fee- 
bly to the interrupted primary current from a hundred-cell battery. 
Reflex excitability was entirely lost. There were no twitchings or spas- 
modic contractions of the paralyzed muscles. Nor had any such move- 
ments ever been noticed. Under the use of ergot, iodide of potassium, 
and the primary galvanic current to the spine and the muscles of the 
lower extremities, he recovered so far as to be able to walk short dis- 
tances with crutches, and obtained full control of his bladder, but there 
was no marked improvement in the sensibility. 

In another case, the affection was apparently induced by excessive 
muscular exertion. "The patient went to bed, feeling fatigued, and in 
the morning was entirely paraplegic. The paralysis gradually extended 
upward, till on the third day both arms were devoid of power. On the 
fifth day I saw him. He was then deprived of voluntary power in both 
upper and lower extremities. Reflex excitability was notably impaired, 
as was also the electric contractility of the muscles. He, however, had 
full power of the bladder and sphincters. On the sixth day the left 
side of his face became paralyzed. He was treated as the case just 
described, and recovered entirely in the course of about two months. 
He has remained perfectly well ever since, and able to attend to his 
business as a commercial traveler. 

Leudet 1 reports several cases in which symptoms similar to those 
present in the foregoing examples were produced by falls and excessive 
muscular exertion, and which were, in his opinion, instances of spinal 

1 " Sur la congestion de la moelle survenant a la suite de chutes et d' efforts yiolents," 
Archives generates, 1860, tome i., p. 257. 



SPINAL CONGESTION. 369 

congestion. In a subsequent paper x he returns to the subject and 
adduces additional cases in support of his view. In his opinion the 
congestion, with its accompanying symptoms, is produced at the end 
of a period often of some hours after the operation of the exciting 
cause. Sometimes the congestion is limited, affecting only a segment 
of the spinal cord ; at others it, from the very first, involves the cord 
throughout its entire length. This fact explains the circumstance that 
the symptoms are by no means . uniform, either as regards their char- 
acter or location. 

Among the effects of working under compressed air, spinal conges- 
tion must be included. Drs. Babington and Cuthbert, 2 of Dublin, have 
called attention to this fact; and Dr. Clark, 3 of St. Louis, has recently 
brought forward several additional cases occurring in the workmen in 
the caisson used in building the bridge over the Mississippi River. 

Passive spinal congestion may be caused by any obstruction to the 
return of blood by the veins, such as cirrhosis of the liver, pregnancy, 
abdominal tumors of various kinds, diseases of the lungs or right side 
of the heart, and the long-continued maintenance of the dorsal decu- 
bitus. 

Diagnosis. — Spinal congestion is liable to be confounded with several 
other affections, and with some to the great injury of the patient. Thus 
it may not be distinguished from spinal anaemia, a condition likewise 
giving rise to paraplegia, but of which the treatment is very different. 

It may be diagnosticated from anaemia of the posterior columns 
by the facts that in it there is pain in the cord, increased by pressure 
on the spinous processes of the vertebrae, or, if there is no spontaneous 
pain, such pressure causes it ; by the disturbance induced in the cranial, 
thoracic, or abdominal viscera, according to the part of the cord af- 
fected being much more prominent; by the circumstance that women 
are more generally its subjects; and that, when there is paralysis, it is 
hysterical and transitory in character. In anaemia of the antero-lateral 
columns there is often a previous affection generally of the urinary 
organs which has caused the anaemia, or some other source of reflex 
irritation or exhaustion can be discovered. Besides, in spinal anaemia, 
either of the posterior or antero-lateral columns, the symptoms are less 
strongly marked after the patient has been lying down some time, 
whereas the reverse is the case in congestion. 

Spinal anaemia never produces any urinary derangement, although 
such trouble may cause spinal anaemia. In a case, therefore, in which 
there was doubt as to the spinal cord being in a state of congestion or 

1 " Recherches cliniques sur la congestion de la moelle a la suite de chutes ou 
d'efforts," Clinique medicale de l'Hotel-Dieu de Rouen, Paris, 1874. 

2 "Paralysis caused by working under Compressed Air," Dublin Quarterly Journal 
of Medical Science. 

3 St. Louis Medical and Surgical Journal. 

25 



370 DISEASES OF THE SPINAL CORD. 

anaemia, the order of sequence, as regards the paraplegia and bladder- 
difficulty, would seem to render the diagnosis exact. In spinal anaemia 
the bladder is affected before the paraplegia appears ; in spinal conges- 
tion the paraplegia comes on before the bladder is involved. 

In spinal anaemia there is no formication, pricking, tingling, or other 
sensation indicative of anaesthesia. Hyperaesthesia is, on the contrary, 
exceedingly common. 

The further diagnostic marks will be considered when we come to 
the subject of spinal anaemia. 

Congestion is distinguished from inflammation of the cord by the 
facts that in it the jerkings of the limbs are slight, that the paralysis is 
not so extreme, that the urine is never alkaline, unless there is paralysis 
of the bladder, that the pain in the cord is less, and by the infrequency 
of the feeling of constriction at the upper limit of the lesion. 

From meningitis it is diagnosticated by the absence of spasms in 
the muscles of the back, and by the fact that movements of the para- 
lyzed limbs do not cause pain. 

Prognosis. — In simple uncomplicated spinal congestion the progno- 
sis is not unfavorable, if, in addition, the case be put under suitable 
treatment at an early period. It must be remembered, however, that 
there is a tendency to interstitial changes, and that, if the vessels of 
the cord be left for a long time in a state of turgidity, it may be im- 
possible to prevent structural alterations of greater severity. In some 
cases, especially those of traumatic cause, the symptoms are quite eva- 
nescent, disappearing in the course of a few hours. It is better, there- 
fore, for the physician to be guarded in expressing his prognosis in 
such instances when recent, till sufficient time has elapsed for the ten- 
dency of the morbid process to be manifested. 

Morbid Anatomy. — The post-mortem appearances in cases of con- 
gestion of the spinal cord are either in the cord proper or its mem- 
branes. As regards the first, section shows increased vascularity both 
of the gray and the white substance, especially if microscopical exam- 
ination be made. The capillaries will be found increased in size and 
more numerous than in the normal condition. 

The membranes of the cord contain very large and very tortuous 
vessels, and in congestion they are rendered still larger and more com- 
plex in their anastomoses. The pressure which they are capable of 
exerting upon the cord is not inconsiderable. 

It is almost invariably found that the cerebro-spinal fluid is in- 
creased in quantity. 

These evidences of congestion are sometimes extremely limited in 
their extent, at others the whole length of the cord is involved. 

Pathology. — The symptoms which result from congestion of the 
cord are of two distinct classes : increased excitability from hyperaemia, 
and interruption of the proper functions of the cord from pressure. 



SPINAL CONGESTION. 37I 

The former, in the main, results from the increased amount of blood 
in the gray matter and white substance ; the latter from the enlarged 
meningeal vessels and the increased amount of cerebro-spinal fluid, 
which, in the form of serous effusion, is the result of their turgidity. 
As one or the other of these conditions predominates, we have some 
symptoms more prominent than others. Thus hyperesthesia indicates 
rather hyperemia of the gray substance, anaesthesia pressure upon the 
white substance. Twitchings, when present, are likewise the result of 
over-excitation of the motor tract ; while motor paralysis is induced 
by pressure upon the antero-lateral columns. 

The modifications which may be produced in the intensity of the 
symptoms by the position of the body show the effect of pressure very 
clearly. In the recumbent posture on the back, the blood gravitates in 
large amount to the spinal vessels, pressure on the cord is increased, 
and the phenomena of anesthesia and paralysis are more strongly 
marked. Again, causes which increase the activity of the circulation, 
such as alcoholic stimulants, and others which directly augment the 
amount of blood in the cord, such as strychnia and phosphorus, invari- 
ably increase the hyperesthesia and induce muscular twitchings, even 
if they have not previously been observed. 

Treatment. — In cases of spinal congestion which come on suddenly, 
and which are therefore acute in their character, such as result from the 
sudden arrest of an habitual discharge, sudden and violent muscular 
exertion, or falls, blood may be drawn locally from the spinal region by 
cups or leeches. The best place for the application of the latter is the 
verge of the anus, and I have several times witnessed very decidedly 
satisfactory results from their use in this situation. 

Purgatives are likewise beneficial, and preference should be given 
to those which produce watery evacuations, as thereby the overloaded 
vessels are relieved, and the absorption of the superabundant cerebro- 
spinal fluid facilitated. Nothing can be better for this purpose than 
the sulphate of magnesia given in doses of a drachm two or three times 
a day. 

In this form the ergot of rye may be given with advantage from the 
very inception of the disorder. In the more chronic form it is indis- 
pensable. It should be administered in very much larger doses than are 
laid down in the text-books on materia medica. I am in the habit of 
using it in this and analogous spinal diseases, in doses of a drachm of the 
fluid extract three times a day. The action of the ergot is to lessen the 
diameter of the blood-vessels of the cord by its constringing power over 
the organic muscular fibre entering into the composition of their walls. 
Ten years ago * I spoke as follows : " But I have recently ascertained 

1 "A Clinical Lecture on Chronic Myelitis, delivered in the Baltimore Infirmary," 
March 16, 1681, American Medical Times, June 15, 1861, p. 379. 



372 DISEASES OF THE SPINAL CORD. 

by actual experiment that ergot does not exert the influence in ques- 
tion. I prepared a weak aqueous infusion of this substance and placed 
it on the web of a frog's foot under the microscope. In a few moments 
contraction of the capillaries ensued, and they became so small as not 
to allow of the passage of the blood-corpuscles. This experiment I 
have repeated several times, and am perfectly satisfied that the result 
is as I have stated. More, I have frequently injected small quantities 
of the infusion into the stomach of irogs, and contraction of the capil- 
laries of the web always followed." 

These experiments, therefore, fully confirmed those made a short 
time previously by Dr. Brown-Sequard. 

Since that time I have given it in a large number of cases of dis- 
eases of the spinal cord, congestion among them, in which it was neces 
sary to diminish the amount of blood in the spinal vessels, and I am 
entirely satisfied that such is its effect ; but I never obtained its full 
influence till, in accordance with the suggestion of Dr. A. Jacobi, of 
this city, I adopted the practice of giving it in what may be called very 
large doses. Among the cases which first came under my care, since 
my residence in New York, was that of Mr. W., of Tennessee, who had 
become affected with congestion of the cord, from exposure to cold and 
dampness. When I first saw him he was unable to walk without the 
assistance of crutches, and a man on each side of him holding his 
shoulder. He had paralysis of the bladder, which had come on after 
the paraplegia, and a constant, dull, aching pain in the loins. There 
were also occasional startings of the legs, especially after he had gone 
to bed. All his symptoms were worse in the morning. I at first gave 
him ten drops of the fluid extract of ergot three times a day, but, con- 
tinuing this for two weeks without effect, I at once increased the doses 
to a teaspoonful. In less than a week the effects were manifest. Sen- 
sibility began to return in the extremities, the strength increased, the 
bladder began to contract on its contents, the lumbar pains ceased, and 
by the end of a month he had entirely recovered. A few weeks after- 
ward he had a relapse, but the ergot, taken as before for ten days, again 
restored him, and he has since remained perfectly well. 

In the case of Mr. T., of Norfolk, Virginia, whose affection was 
apparently the result of exposure to cold and dampness, and who wa 
barely able to walk with two canes, a complete cure was accomplished 
by the use of ergot continued for about a month. In two other cases 
occurring in mechanics of this city, ergot was the only remedy em- 
ployed, and both were entirely cured in less than a month. 

In several cases I have administered the ergot hypodermically in 
doses of five grains daily of Beaujon's extract, but I am convinced that 
nothing is gained by this course. As regards the efficacy of ergot in 
spinal congestion, there is not, in my opinion, any doubt. Even 
when it fails to effect a cure, its good influence is at least shown 



SPINAL ANEMIA. 373 

for a time. I would as soon think of treating intermittent fever with- 
out quinine as congestion of the spinal cord without ergot. 

Belladonna is also a valuable remedy in spinal congestion, especially 
when there is paralysis of the sphincter, or when the pain in the back 
is severe. The tincture, in doses of fifteen drops three times a day, 
may be employed, and a belladonna plaster may be applied to the pain- 
ful region of the spine. 

The hot douche — the water being of the temperature 01 98° Fahr. — 
to the spinal column is an excellent means of determining the blood 
from the deep to the superficial vessels. The water should be allowed 
to fall from the height of about two feet upon the naked back over the 
diseased part of the cord every day for about five minutes. Dry cups 
are also valuable adjuncts. 

Electricity is always useful. The constant current should be applied 
to the spine over the affected part of the cord, and the intensity and 
quantity should be as great as the patient can endure without much 
discomfort. I am not sure that it makes any difference in which direc- 
tion the current be passed. Of its benefit I have no doubt. The dura- 
tion of the application should not exceed ten minutes. The beneficial 
effect is probably due to the diminution of the calibre of the blood- 
vessels through its action on the vaso-motor nerves. 

The induced current should be used to the paralyzed muscles, so as 
to excite them to contract. In this way their nutrition is promoted, 
and any tendency to atrophy from disuse obviated. 

The primary current should not be employed more frequently than 
every alternate day. The induced may be used every day for half an 
hour or longer, short of causing fatigue. 

I will only add that strychnia and phosphorus should never be ad- 
ministered in congestion of the cord, as their action is the very reverse 
of that desired, and irreparable damage may be done by their use. 



CHAPTER II. 

SPIRAL ANAEMIA.— ANEMIA OF THE POSTERIOR COLUMNS.— ANAEMIA OF 
ANTERO-LATERAL COLUMNS. 

A deficient quantity of blood in the spinal cord, or a depravation 
in the quality of the blood circulating through its tissue, gives rise to 
two cognate, but, so far as their phenomena go, different affections. In 
one of these, which has hitherto been known as spinal irritation, the 
morbid action, is in a great measure confined to the posterior columns 
of the cord ; in the other, which embraces several differently-named 
disorders, characterized by paralysis, such as reflex paralysis, inhibitory 



374 DISEASES OF THE SPINAL CORD. 

paralysis, spinal paresis, paralysis from peripheral irritation, etc., the 
antero-lateral columns are mainly affected. 

In thus specifically locating the lesions in these affections, I am 
aware of the fact that post-mortem examinations are wanting to sup- 
port them. Nevertheless, the symptoms characteristic of each are so 
distinctly marked, and are in such intimate physiological relation with 
the regions of the cord specified, that I do not think I am at all exceed- 
ing the limits of probability. 

Retaining the name of spinal irritation, as one well known to the 
profession, it will nevertheless be understood that, in my opinion, the 
proper designation of the disease would be anaemia of the posterior col- 
umns of the spinal cord. I have arrived at this view after a very care- 
ful consideration and analysis of the symptoms observed in a large num- 
ber of cases. 

The same remarks are applicable, mutatis mutandis, to reflex para- 
plegia, a symptom which I am very sure results from anaemia of the 
antero-lateral columns of the cord. 



ANAEMIA OF THE POSTERIOR COLUMNS OF THE SPINAL CORD. SPINAL 

IRRITATION. 

History. — It has been questioned by several distinguished authors 
whether such an affection as spinal irritation really exists as a distinct 
disease. Thus Valleix * ascribes the most important of its manifesta- 
tions to hysteria, and regards the spinal tenderness present as being 
due to simple intercostal neuralgia ; Inman 2 considers the pain pro- 
duced by pressure over the spinous processes of the vertebrae as exist- 
ing in the muscular attachments, and as indicative of what he calls my- 
algia. Mr. Skey 3 evidently looks upon all cases of spinal irritation as 
hysterical in their character, and Niemeyer 4 speaks incredulously on 
the subject, without giving any very decided opinion. It would be 
easy to bring forward other authorities who have expressed similar 
views, and I may have to allude to some of them more fully hereafter. 
In the recently-published nomenclature of the Royal College of Physi- 
cians, 6 the affection has no place unless it be included under the head of 
hysteria. 

The first author who distinctly grouped together the symptoms of 

1 "Traite des nevralgies, ou affections douloureuses des nerfs," Paris, 1841, p. 345. 
9 " On Myalgia : its Nature, Causes, and Treatment," etc., second edition, London, 
1860, p. 225, et seq. 

3 " Hysteria," etc., New York, 1867, p. 72, et seq. 

4 "A Text-Book of Practical Medicine," American edition, New York,' 1869, vol ii. 
p. 258. 

6 " The Nomenclature of Diseases drawn up by a Joint Committee appointed by the 
Royal College of Physicians of London," London, 1869. 



SPINAL ANAEMIA. 375 

epinal irritation was J. Frank, 1 who, under the name of rachialgia, de- 
scribed the disorder with considerable accuracy, and laid the principal 
stress upon the local pain. He was followed by Stiebel, 2 who, however, 
contributed little to our knowledge of the subject. 

Mr. J. R. Player 3 was among the first English physicians, if not the 
very first, to call attention to the fact that eccentric derangement of 
function may be the result of irritation of the spinal cord. Thus he 
says : " Most medical practitioners who hare attended to the subject 
of spinal disease must have observed that its symptoms frequently re- 
semble various and dissimilar maladies, and that commonly the function 
of every organ is impaired whose nerves originate near the seat of dis- 
order. The occurrence of pain in distant parts forcibly attracted my 
attention, and induced frequent examination of the spinal column ; and, 
after some years' attention, I considered myself enabled to state that, 
in a great number of diseases, morbid symptoms may be discovered 
about the origins of the nerves which proceed to the affected parts, or 
of those spinal branches which unite them ; and that, if the spine be 
examined, more or less pain will commonly be felt by the patient on the 
application of pressure about or between those vertebras from which 
such nerves emerge." 

The term " spinal irritation " appears to have been first used by Dr. 
C. Brown,* of Glasgow, who, in a very excellent paper, gives a picture 
of the disorder which cannot fail to be recognized as truthful and exact 
by those who have witnessed several cases of the affection. He insists 
upon not confounding the complaint with those organic diseases of the 
vertebras and spinal cord which some of its symptoms cause it to resem- 
ble, points out the variation of the phenomena according to the seat of 
the spinal tenderness, and inculcates the employment of rest and coun- 
ter-irritation as the most effectual remedies. His ideas of the patholo- 
gy of the disease are : " That the immediate cause of the pain of the 
back and breast is spasm of one or other of the muscles arranged along 
the spine altering the position of the vertebrae, or otherwise compress- 
ing them as they issue from the spinal marrow. 

" That this spasm in many instances is strictly a local disease, pro- 
duced by fatigue, wrong posture, or other causes, and quite uncon- 
nected with the state of the brain, spinal marrow, or nervous system 
in general. 

" But that, in other formidable instances, this partial, spasmodic, or 
wrong action of the muscles, is owing to a faulty state, perhaps an 
enlargement, of the vessels of the brain or spinal marrow. This state 
of the brain, as in many other diseases, gives rise to spasm or even to 

1 " De Rachialgitide" in Prax. med. univ., P. II., t. i., p. 37. 

9 "Ueber Neuralgica Rachitica," Rusfs Magazine, t. i., c. xvi., p. 549. 

8 Quarterly Journal of Science, vol. xii., p. 428. Quoted by Teale. 

4 " On Irritation of the Spinal Nerves," Glasgow Medical Journal, No. II., May, 1828. 



376 DISEASES OF THE SPINAL CORD. 

convulsion of certain muscles ; which partial symptom, from its sever- 
ity, attracts the chief attention. This local affection is confined to 
those portions of the spine where there is the greatest motion, and 
where, of course, the muscles having the greatest activity are most 
liable to deranged action or spasm. I imagine that this view of the 
subject is illustrated and perhaps confirmed by various symptoms which 
were observed in the different cases, and which without it were very 
incomprehensible. The partial palsy, the affection of the sight, the 
giddiness of the head (for I find that this was a prominent symptom in 
several cases, especially in that of A. S.), all give some confirmation to 
the notion that the brain is affected in these severe cases." 

Dr. Darwall, 1 of Birmingham, describes several features of the affec- 
tion with accuracy, such as those simulating cardiac and gastric dis- 
eases. He is inclined to believe that the morbid condition of the spinal 
cord depends mainly upon irregularity of the circulation, generally 
congestion. 

But no essay upon the subject of spinal irritation, which had yet 
appeared, was equal in thoroughness to that of Mr. Teale, 2 and it is to 
him that the views now generally held relative to the connection be- 
tween various eccentric phenomena, such as pain, spasm, and visceral 
disturbance, and a peculiar condition of the spinal cord, are to be 
attributed. He, however, committed the great error of regarding the 
affection as being due to inflammation, and, in what for those days was 
logical accordance with this theory, he combated it with strong anti- 
phlogistic measures. His book may be studied with advantage, as 
presenting an admirable account of the -many diverse phases which 
spinal irritation may assume. 

Mr. Tate, 3 in his work on hysteria, attributes many of the protean 
manifestations of this disorder to spinal irritation, limited, however, to 
the dorsal region. He fails to recognize it as an independent disease. 
His treatment consists in the application of tartar-emetic ointment 
along the whole length of the dorsal vertebrae, and strong purgation. 
He discountenances the use of leeches and blisters. 

Mr. W. R. Whatton 4 insists chiefly upon the liability to mistake 
spinal irritation for disease of the vertebrae. He gives a very excellent 
account of the symptoms. The treatment he recommends consists in 
the abstraction of blood, by leeches or cups, from the parts where the 
tenderness is felt, repeated every three or four days, and the applica- 

1 "On some Forms of Cerebral and Spinal Irritation," Midland Medical Reporter, 
May, 1829. 

2 " A Treatise on Neuralgic Diseases dependent upon Irritation of the Spinal Marrow 
and Ganglia of the Sympathetic Nerve," London, 1829. 

3 " Treatise on Hysteria," London, 1830. 

4 " On Spinal and Spino-Ganglial Irritation," North of England Medical and Surgical 
Journal, No. Ill, 1831. 



SPINAL ANEMIA. 377 

tion of small blisters on each side of the painful spots. Any debility 
ensuing in consequence of this treatment is to beremedied by the prep- 
arations of iron and quinine. 

In a clinical lecture delivered in Dublin, Dr. Corrigan * relates the 
particulars of several cases of spinal irritation, successfully treated by 
local antiphlogistic measures, and the internal use of iron. He does 
not, however, add any thing of importance to our previous knowledge 
of the subject. 

Dr. Isaac Parish, 2 of Philadelphia, appears to have been the first 
American author who called attention to the affection in question. He 
relates the details of several cases, recommends the use of counter- 
irritants, especially tartar-emetic ointment, and concludes : 

" First, that tenderness on pressure in some portion of the spinal 
cord is an attendant on many chronic neuralgic affections, and that, by 
relieving it in the manner proposed, these complaints are either entirely 
eradicated or temporarily suspended. 

u And, secondly, that the precise indications which this circumstance 
affords are not sufficiently understood at the present time to justify the 
establishment of any definite pathological principles applicable to the 
whole class of neuroses." 

Dr. W. Griffin and his brother, Mr. D. Griffin, 3 of Limerick, were 
the next to write upon the subject. The joint work of these gentlemen 
is based upon one hundred and forty-eight cases, all of which are thor- 
oughly analyzed, and from which very definite deductions of pathology 
and treatment are drawn. The essay is not excelled in importance by 
any previous contribution, and' constitutes a really valuable study. The 
conclusions which they draw are so instructive that I do not hesitate 
(though by no means indorsing them all) to transfer them without 
abbreviation : 

" 1. That tenderness at one or more points of the spine is an at- 
tendant on almost all hysterical complaints, on numerous cases of func- 
tional disorder when the hysteric disposition is not so obvious, and in 
many nervous or neuralgic affections. 

" 2. That many of the symptoms of these affections evidently depend 
upon a peculiar state of certain nerves, probably at their origin, may be 
reproduced at any moment by pressure, and are often relieved by rem- 
edies applied there. 

" 3. That, in all cases of tenderness of the cervical and upper dorsal 
spine, there was nausea, or vomiting, or pain of stomach, or affections 

1 Medico- Chirurgical Jtevieio, July, 1831, p. 182. 

2 " Remarks on Spinal Irritation as connected with Nervous Diseases : with Cases," 
American Journal of the Medical Sciences, vol. x., 1832, p. 223. 

4 " Observations on the Functional Affections of the Spinal Cord and Ganglionic 
Nerves, in which their Identity with Sympathetic, Nervous, and Simulated Diseases is 
illustrated," London, 1834. 



378 DISEASES OF THE SPINAL CORD. 

of the upper extremities ; but no pain of the abdomen, dysury, ischury, 
hysteralgia, or affections of the lower extremities. 

" 4. That, in all cases of iorsal tenderness, pains affecting the abdo- 
men, bladder, uterus, testes, or lower extremities, were usual symp- 
toms ; while nausea, vomiting, or affections of the upper extremities, 
were never complained of. 

" 5. That nausea and vomiting appeared to have more relation to 
tenderness of the cervical spine, pain of stomach to tenderness of 
dorsal ; but that, when there was soreness of both, nausea or vomit- 
ing was still more frequent, and pain of the stomach scarcely ever absent. 

" 6. That, when several points or a great extent of the spinal 
column is painful and tender on pressure, local remedies are generally 
less effectual, and there is a strong disposition to transference of the 
disordered action from one organ to another ; the pain or tenderness 
in all such cases of transference, shifting its place to a corresponding 
part of the spinal column, leaving the original point free, or with a very 
diminished degree of tenderness. 

" 7. That spinal tenderness is seldom or never met with in cases of 
pure inflammation, except when these accidentally occur in persons 
previously suffering from irritation of the cord ; and that, when appear- 
ances of inflammation present themselves in any organ accompanied by 
a corresponding spinal tenderness, they cannot commonly be removed 
by the remedies applicable to inflammatory cases, and are often ren- 
dered worse by them. 

" 8. That there does not appear to be a complaint to which the human 
frame is liable, whether inflammatory or otherwise, which may not be 
occasionally imitated in disturbed states of the cord ; and hence that 
this disturbed state is one vast source of those complaints called hyster- 
ical or nervous. 

" 9. That those functional disorders connected with spinal tenderness 
are very often attended by some disturbance of the functions of the 
uterus, but that they are by no means always so, since they occur in 
those who are regular in this respect : in girls long before the menstrual 
period of life, in women after it has passed, and, Jastly, in men of ner- 
vous susceptible habits, and in boys. 

" 10. That in fact they are not necessarily dependent upon any one 
organ ; since they are found indifferently coexisting with disturbance 
of the digestive organs solely, or the uterus solely, or of the circulatory 
or respiratory system. 

" 11. That from the cases detailed we have reason to suppose spinal 
tenderness may arise from uterine disorder, from dyspepsia, from worms 
in the alimentary passages, from affections of the liver, from mental 
emotions, from the poison of typhus, from marsh miasmata, from erysipe- 
latous, rheumatic, and eruptive fevers, and from the irritation arising 
from local injury. 



SPINAL ANEMIA. 379 

" 12. That it is almost invariably found, in connection with gastric 
or abdominal tenderness, in fever ; and this tenderness is, probably, like 
the soreness of scalp, pains in the limbs, etc., dependent on the morbid 
state of the cord. 

"13. That, whether in fever or in other complaints, it is met with 
in the situation of the eighth or ninth dorsal vertebra much more fre- 
quently than at any other part of the spine. 

" 14. That affections attended by spinal tenderness are seldom fatal ; 
that, even in those cases of intense irritation of the cord under which 
patients suffer extremity of pain for years, the event is generally favor- 
able. 

" 15. That they frequently, as well as hysteria, occur with all the 
appearances of a primary affection of the nervous system. 

"16. That affections are occasionally met with presenting all the 
marks of the hysteric character, and perfectly resembling cases described 
as those of spinal irritation, but unattended by spinal tenderness or any 
jther direct indication of a morbid state of the cord." 

The treatment recommended consists in the removal of the cause if 
this still continues in action, purgatives, the application of blisters and 
leeches to the skin, the internal administration of hyoscyamus and bel- 
ladonna, to lessen the nervous irritability, alum in cases of gastric de- 
rangement, and change of air and scene. 

In a subsequent work, the Messrs. Griffin * again discuss the sub- 
ject, but bring forward no additional facts. 

Dr. John Marshall 2 is confident that many visceral affections, such 
as heart-diseases, asthma, phthisis, dyspepsia, diabetes, chorea, and even 
phlegmasia dolens, are frequently really produced or simulated by spi- 
nal irritation. Some of his cases of supposed functional disorder of the 
spinal cord are, however, obviously organic, consisting of congestion, 
inflammation, or softening -of the organ. 

In his classical work, Ollivier 3 devotes considerable space to what 
he calls " an Affection described under the name of Spinal Irritation" 
He considers the pathological condition to be one of congestion of the 
meninges of the cord, and bases this opinion in great part" on the suc- 
cess which, according to him, ensues on the use of leeches, blisters, and 
counter-irritant ointments. In addition, he favors the administration 
of opium, digitalis, hyoscyamus, belladonna, and subcarbonate of iron. 
Turck 4 regards the phenomena of spinal irritation as being due, 

1 " Medical and Physiological Problems : being chiefly Researches for Correct Princi- 
ples of Treatment in Disputed Points of Medical Practice," London, 1845. 

2 " Practical Observations on Diseases of the Heart, Lungs, Stomach, Liver, etc., oc- 
casioned by Spinal Irritation, and on the Nervous System in General as a Source of Or- 
ganic Disease," London, 1835. 

3 "Traite des maladies de la moelle epiniere," troisieme edition, Paris, 1837, tome 
seconde, p. 209. 

4 "Abhandlung iiber spinal Irritation," u. s. w., "Wien, 1843. 



380 DISEASES OF THE SPINAL CORD. 

first, to disorder of other organs, whereby a morbid impression ia 
propagated along the incident excitor nerves to the spinal cord ; or, 
second, to derangement of the capillary circulation of the cord. That 
is, the disease may be either of eccentric or centric origin. He does not 
advance our knowledge beyond the point reached by previous authors. 

Coming again to our own country, we find that in 1844 a very valu- 
able paper was published by Prof. Austin Flint, 1 based upon fifty-eight 
cases of functional disorder connected with an abnormal condition of 
the spinal cord. In this memoir, without going into any discussion rela- 
tive to the pathology of the affection, Dr. Flint considers the disorder 
as giving rise to tenderness over the vertebral column, causing altera- 
tions of sensibility, as affecting the muscular system, as producing abnor- 
mal mental manifestations, as affecting the digestive organs, the genito- 
urinary organs, the heart and circulation, and as causing paroxysms of 
sinking. He then considers the physical habits of the patients, the re- 
sults of medical treatment, the probable remote causes, and then, at 
some length, the remedial measures which he has found most successful. 
Under this head, Dr. Flint . advises the use of counter-irritants to the 
spine, especially cupping, and generally without scarification. Issues 
he found inapplicable, death ensuing in the one case in which he used 
them. There is no doubt, however, that in this instance he had an or- 
ganic disease to deal with, and that the issues had nothing to do with 
the fatal result. Tonics, especially iron, he found to be of great advan- 
tage. 

In a very full analysis of the medical reports of the Stockholm Hos- 
pital by Dr. Magnus Huss, 2 the subject of spinal irritation receives due 
consideration. Dr. Huss classes the symptoms of the disorder as fol- 
lows : 1. Pain of various parts of the vertebral column, existing either 
idiopathically or developed by pressure. 2. Cramps, either of a clonic 
or tonic nature, in those parts subjected to the influence of the spinal 
cord. 3. Loss of power in the same portions of the body, ranging from 
simple stiffness and weakness to complete paralysis. 4. Altered sensi- 
bility, either by excess or by great diminution of sensation. 

It will be observed that in this enumeration the author confines his 
specification of morbid phenomena to those which relate to sensation 
and the power of motion. 

The treatment is fully and philosophically considered. Of external 
remedies he prefers counter-irritants, using the milder forms first, and 
then the severer, such as the moxa and the actual cautery, should the 
first fail. Venesection, either general or local, should be cautiously 
employed, and is not generally indicated. He is the first, so far as my 
researches extend, to mention electricity, a means which he thinks may 

1 "Observations on the Pathological Relations of the Medulla Spinalis," American. 
Journal of the Medical Sciences, April, 1844, p. 269. 

i British and Foreign Medical Review, October, 1846, p. 463. 



SPINAL ANAEMIA. 381 

be employed with advantage in chronic and debilitated cases. Potash- 
baths are also recommended. 

Of internal remedies he specifies iron, opium, strychnia, phosphorus, 
and valerian, as being preeminently useful. 

Axenfeld x devotes a considerable portion of his treatise to spinal 
irritation. He regards it as being produced either by a trouble of in- 
nervation or congestion. In the treatment, leeches occupy the first 
place, and in light cases blisters, sinapisms, dry cups, and stimulating 
frictions, are useful. Internally he recommends nothing but quinine 
and iron. 

Dr. Radcliffe 2 writes very sensibly on the subject of spinal irrita- 
tion, and gives a typical case which is quite instructive. He incident- 
ally gives it as his opinion, that the pathological condition is one of 
anaemia, and he consequently discourages the use of leeches, relying 
mainly on blisters and tonics. 

Leyden 8 declines to recognize spinal irritation as a distinct patholo- 
gical entity, regarding it as a condition which may result from other 
primary affections. In this he very generally mistakes cause for effect. 
His remarks are evidently more based on theory than practice, for it is 
very apparent he has seen little or nothing of the disorder under con- 
sideration. 

Rosenthal 4 barely mentions it under the head of hysteria. 
Erichsen, 6 with more practical acumen, says of spinal anaemia, and 
especially of anaemia of the posterior columns of the cord, that it is 
" a condition which we rather recognize clinically than pathologically, 
by analogy than by direct post-mortem demonstration, by therapeutical 
rather than by physiological tests. But yet it is a condition which is 
now fully recognized as probable, in lieu of positive evidence, by the 
best and most modern writers on nervous diseases, and one the prob- 
able existence of which we may accept." 

I have thus cited the principal authorities upon spinal irritation, 
without, however, by any means, exhausting the bibliography of the 
subject. Notwithstanding the eminence of many of those who have 
contended for the existence of a definite affection of the spinal cord, 
characterized by tenderness on pressure over one or more of the verte- 
brae, and certain eccentric disorders involving sensibility, the power of 
motion, and functional derangement of many of the viscera, it must be 
confessed that the great mass of the medical profession has regarded 
the whole theory with suspicion, if not with absolute distrust. The 

1 " Des Nevroses," Paris, 1863, p. 284. 

2 Reynolds's " System of Medicine," London, 1868, vol. ii., p. 640. 

* " Klinik der Ruckenmarks-Krankheiten," zweiter Band, erste Abtheilung, Berlin, 
1 375, p. 1, et seq. 

4 "Klinik der Xerven-Krankheiten," Stuttgart, 1875, p. 440. 

6 "On Concussion of the Spine," etc., London, 1875, p. 188, ei ieq. 



382 DISEASES OF THE SPINAL CORD. 

principal reason for this is undoubtedly to be found in the fact that, 
like many other hew theories, that of spinal irritation has been 
applied to explain conditions which it could not logically be made to 
cover. Thus many cases of disease or disorder of the heart, due to 
organic difficulties of that organ, or excited by disease of other viscera 
through the sympathetic system, have been attributed to spinal irrita- 
tion. The same is true also of the uterus, stomach, liver, and other 
organs, and even of the spinal cord itself, which often, when the seat 
of organic diseases, such as congestion, meningitis, inflammation, tu- 
mors, etc., has been regarded as simply in a state of irritation. It is 
very certain, also, that numberless cases of hysteria have been attrib- 
uted to irritation of the spinal cord. In the following remarks I will 
endeavor to be as explicit as possible, and not to claim too much for a 
pathological condition which I am very sure exists, and which I there- 
fore think is entitled to recognition. If I contribute any additional 
information, it will be mainly due to the fact that our means of exami- 
nation are much more perfect and extensive, and our knowledge of 
physiology, pathology, and therapeutics, more thorough than when 
most of the authors I have quoted wrote upon the subject. My observa- 
tions are based upon a careful study of one hundred and twenty-seven 
cases which have occurred in my private practice during the last six 
years, and of which I have full notes, and twenty-nine cases of which I 
have less complete data — in all, one hundred and fifty-six cases. 1 

Symptoms. — Centric Symptoms. — 1. Tenderness at some one or 
more Points over the Spinal Column, increased by Pressure. — This is 
the essential symptom of spinal irritation, though varying in intensity 
from the slight degree of pain experienced upon strong pressure to the 
acute hyperesthesia which does not allow of even the contact of the 
clothing without the production of great suffering. It is generally com- 
plained of by the patient, though occasionally it has to be sought for 
by the physician. The brothers Griffin found this symptom present 
in all but five out of one hundred and forty-eight cases, and it is very 
probable that these five were not cases of spinal irritation, a supposi- 
tion which the authors themselves evidently entertain. Certainly the 
details of the cases do not support the view which' would ascribe their 
phenomena to any affection of the spinal cord. Most of the other 
authors I have cited refer to this tenderness as a prominent feature. 
Parish thinks it alone is to be relied upon as indicating irritation; Mr. 
Whatton declares that it is never wanting ; Axenf eld regards it as 
the dominant and characteristic symptom ; and Radcliffe, while admit- 
ting that it is not equally well marked in every case, states the rule to 
be that spinal tenderness and spinal irritation go together. 

1 Since the first edition of this work was published, a large additional number of 
cases of spinal congestion have come under my notice, but, as I have kept no full record 
of them, I have allowed the statement in the text to remain unaltered. 



SPINAL ANAEMIA. 383 

■ 

On the other hand, Flint does not regard tenderness as an invari- 
able and essential element of the affection under consideration. He 
found it absent or indistinct in five of his fifty-eight cases, while the 
other attendant circumstances furnished unequivocal evidence that the 
diagnosis was correct. 

My own opinion would lead me to consider no case as one of spinal 
irritation in which tenderness on pressure over the vertebras was ab- 
sent. In the one hundred and fifty-six cases noted by me, this symptom 
was present in all. There are diseases of the spinal cord, which pro- 
duce derangements of other organs of the body, and which are not 
characterized by vertebral tenderness, but these are far more serious 
affections than spinal irritation, and of altogether different pathology. 

The seat of the tenderness is generally in the dorsal region of the 
spine. The Griffins found cervical tenderness in twenty-three cases, 
cervical and dorsal tenderness in forty-six, dorsal alone in twenty-three, 
dorsal and lumbar in fifteen, lumbar in thirteen, the whole spine tender 
in twenty-three, and no tenderness in five. Of one hundred and forty- 
eight cases, therefore, one hundred and seven exhibited tenderness in 
the dorsal region. 

Dr. Flint found cervical and dorsal tenderness in three cases, lum- 
bar and dorsal in ten, and dorsal alone in twenty-one cases. 

Of my own cases, twenty-five had cervical tenderness only, thirty- 
seven cervical and dorsal, forty-five dorsal only, nineteen dorsal and 
lumbar, fifteen lumbar only, and in fifteen the whole spine was tender. 
One hundred and sixteen cases, therefore, of one hundred and fifty-six 
were characterized by dorsal tenderness, and in forty-five it was limited 
to this region. 

The degree and character of the tenderness are subject to great 
variation. In some cases strong pressure is required to develop it, 
while in others the least touch is insupportable. Sometimes there are 
shooting pains, which radiate from the tender spot, while at others the 
hyperesthesia is quite circumscribed. In a gentleman now under my 
care with well-marked spinal irritation, and who has a tender spot over 
the third lumbar vertebra, pressure not only causes intense suffering at 
that point, but develops pain along the whole course of the crural nerves 
and their branches as far as their terminations on the inner sides of the 
feet. Another, a lady, who has spinal tenderness over the eighth cer- 
vical and first dorsal vertebras, experiences, from pressure, intense pain 
along the course of the first intercostal, the internal anterior thoracic, 
and all the nerves of the left upper extremity. Why in these and other 
cases particular nerves should be affected, is a question which will be 
more fully considered hereafter. 

The pain developed by pressure is not always of the same character. 
Sometimes it is dull and aching, and' at others sharp and lancinating. 
I have not noticed that any very definite relation exists between the 



384 DISEASES OF THE SPINAL CORD. 

character of the pain and the severity of the other symptoms, though, 
as regards the degree of pain of each kind, there is a marked connec- 
tion. By this I mean that a dull, aching sensation may indicate as pro- 
found a pathological condition, and be accompanied by as intense eccen- 
tric phenomena, as a sharp and lancinating pain, though a severe ach- 
ing pain and a severe lancinating pain always indicate more serious dis- 
order than when these sensations are not so emphatic. 

The character of the pain varies in accordance with the tissue in 
which it is felt. The dull aching sensation is only developed by strong 
pressure, and is seated in the muscular, tendinous, or cartilaginous 
structures about the vertebrae. The sharp, piercing twinges excited by 
slight pressure' arise from the skin, and subcutaneous cellular tissue. 
With these species of sensations, the aasthesiometer always shows in- 
creased sensibility of the skin over and in the vicinity of the painful 
centres. 

To ascertain whether or not the tissues outside of the spinal canal 
are in a state of hyperesthesia, the pressure should be applied with 
gradually-increasing force, by means of the thumbs applied to the 
spinous processes and the intervertebral spaces, as recommended by 
Flint. The examination should be thorough, and extend throughout 
the whole extent of the vertebral column. The fact that the patient 
denies the existence of tenderness should have no weight with the phy- 
sician. Only a few days ago a young lady consulted me for severe 
infra-mammary pain, headache, and nausea. I at once suspected spinal 
irritation, but she declared, in answer to my inquiries, that there was 
no sign of tenderness anywhere over the spinal column. I insisted, 
however, on a manual examination, and to her great surprise found 
three spots that were exceedingly painful to slight pressure. This 
young lady had been treated for dyspepsia for several years, without 
deriving any benefit from the measures used, but was cured by the 
treatment which I shall presently fully consider. -Occasionally it hap- 
pens that the tenderness is not perceived for some time after the press- 
ure is made. In a recent case I found the interval to be over a min- 
ute, and then acute pain, following the course of the nerves, was ex- 
perienced. I am not prepared to offer an explanation of this phenome- 
non. 

2. Pain in the Spinal Cord. — The tenderness just noticed is seated 
primarily externally to the vertebral canal, and is developed by press- 
ure. That which is now to be considered is located in the spinal cord, 
and is, therefore, capable of being produced by pressure upon non-ten- 
der spots. It is a very common symptom, having been present in one 
hundred and one of my cases. Generally it is confounded with spinal 
tenderness, from which, however, it is quite distinct. It is aggravated 
by motion of the spinal column, by action of the muscles which have 
their attachments to the spinous and transverse processes, by percus- 



SPINAL ANEMIA. 385 

sion, and sometimes by the erect posture. In the case of a gentleman 
of this city, it was so great when he stood up that he was forced to keep 
the recumbent position nearly the whole time. When I first saw him 
he was wearing an apparatus designed to keep the weight of the head 
from the vertebral column, and to prevent the vertebras pressing upon 
each other, under the idea that he had disease of the intervertebral sub- 
stance. I removed the instrument, and, treating him for spinal irrita- 
tion, he recovered his health in a few weeks. 

Pain in the spinal cord, in the disorder under consideration, is usu- 
ally seated near the point of external tenderness, though it is often at 
a distance, and sometimes is felt throughout the whole extent of the 
cord. The eccentric phenomena bear a distinct anatomical and physio- 
logical relation to it, as do those which are connected with spinal ten- 
derness. There is likewise a similar connection existing between the 
pain in the cord and the vertebral tenderness. 

To ascertain the existence of spinal pain, when it is not spontane- 
ously felt or superinduced by muscular exertion, percussion should be 
practised. The ends of the fingers will answer for this purpose, though 
I prefer a little vulcanized India-rubber hammer, and a plessimeter, such 
as are sometimes used for percussing the chest. Even over spots which 
exhibit much tenderness, the deep-seated pain in the cord itself can 
clearly be distinguished. 

Eccentric Symptoms. — By far the most important and noticeable 
symptoms of spinal irritation are to be found in distant parts of the 
body. These vary in their character and seat, according to the part of 
the spinal cord affected. Following the example of the Griffins, I shall 
consider these symptoms as they depend upon irritation of the several 
regions of the cord with which they are connected. 

a. The Cervical Region. — Of the cases upon which this chapter is 
based, in twenty-five the irritation existed in the cervical region only, 
of the spinal cord ; in thirty-seven, the cervical tenderness was con- 
joined with dorsal tenderness, and in fifteen with tenderness of the 
whole spine. Taking the uncomplicated cases as presenting the clear- 
est features, the following would appear to be the more prominent 
symptoms of cervical spinal irritation. 

Vertigo was an accompaniment in eleven cases, and headache in 
fifteen ; noises in the ears in eight, and disturbances of vision in four. 
Fullness and a sense of constriction across the forehead were complained 
of in several cases, as was also tenderness of the scalp. In addition, 
the mind was more or less affected in every case, and in seven the ab- 
erration was of such a character as almost to amount to insanity. In 
one of these, a married lady, aged thirty, there were several paroxysm? 
of maniacal excitement every day ; and in another, that of a young 
lady aged twenty-three, so furious were the exacerbations that, for fear 
she would injure herself or others, she had to be restrained by twc 
26 



386 DISEASES OF THE SPINAL CORD. 

strong nurses, who held her while the fits lasted. The predominant 
type, however, was melancholia. 

Sleep was deranged in every case, generally in the form of insomnia, 
though in three cases the tendency to somnolence was excessive. In 
every case the dreams were of an unpleasant character ; in two there 
was nightmare, and in one somnambulism. 

Neuralgic pains were present in seventeen of the twenty-five cases. 
If the upper part of the cervical region was the seat of the irritation, 
these pains were experienced in the scalp and face ; if the lower, they 
were seated in the neck, the shoulders, upper part of the chest, and the 
upper extremities. Sometimes the pain was of a dull, burning charac- 
ter, and was then generally seated in the muscles of the nucha. Mus- 
cular effort always increased the suffering. In accordance with Teale's 
experience, it several times occurred that the neuralgia was intermit- 
tent, the paroxysms coming on about sundown and lasting through the 
night. In none of these cases was there anaesthesia. 

Motility was interfered with in eighteen cases. Sometimes there 
were fibrillary twitchings / in five cases there were clonic spasms of 
the muscles of the face and neck ; in three, general chorea y in two, 
contractions of the flexors of the arm on one side, so that the elbow 
was rigidly bent ; in two, the contractions were in the flexors of the 
hands, and in four, of the fingers. In one case there was complete loss 
of power over the hand ; in four, aponia / and in one, almost constant 
hiccough while the patient was awake. 

Nausea was present more or less in fifteen cases, and, in one, part 
of every thing taken into the stomach was almost immediately rejected. 
Pain in the stomach was not met with in any case. 

b. The Dorsal Region. — I found the dorsal region of the spine ten- 
der in one hundred and sixteen cases. In thirty-seven of these it was 
conjoined with cervical, in nineteen with lumbar tenderness, and in fif- 
teen it was affected with the whole spine, leaving forty-five uncompli- 
cated cases. 

The most prominent symptoms in these cases were connected with 
the viscera, the stomach being the organ commonly involved. Thus, 
gastralgia was present in every case, nausea and vomiting in nine cases, 
pyrosis in three, gastric flatulence in forty, and acidity ', as evidenced 
by heartburn, in twenty-six. 

Next in order came the heart. There were palpitations in twenty- 
six cases, fits of oppression, during which the heart beat with irregu- 
larity as regarded force and rhythm, in ten cases, and attacks of syn- 
cope in five. There was difficulty of breathing in fifteen cases, and 
cough in fifteen. Intercostal neuralgia existed in ten, and infra- 
mammary pain in thirty-one cases. 

There were no muscular spasms, contractions, or paralysis. 

In the thirty-seven cases in which the dorsal tenderness was con- 



SPINAL ANiEMIA. 387 

joined with cervical tenderness, the symptoms characteristic of each 
region were more or less intermingled. In two cases there was 
epilepsy, and in three chorea paralytica. 

c. The Lumbar Hegion. — This portion of the spine exhibited ten- 
derness in forty-nine cases. In nineteen of these it was accompanied 
by dorsal tenderness, in fifteen the whole spine was affected, and in fif- 
teen the tenderness was confined to the lumbar region alone. Of these 
latter all were characterized by neuralgic pains in the lower extremi- 
ties, and in three of them there were similar pains in the muscles of 
the back and abdomen. In six there was spasm of the neck of the blad- 
der, accompanied with severe pain, and causing great difficulty of uri- 
nating, in one there was incontinence of urine, in five pain in the ute- 
rus and ovaries, and in one neuralgia of the rectum. 

Motility was affected in eight cases. In four of these there were 
strong tonic contractions of the muscles of the lower extremities, and 
in four paralysis. In all of these there were occasional clonic spasms 
simulating chorea. Of the nineteen cases in which there was also 
dorsal tenderness, the symptoms were in general those characteristic 
of spinal irritation of both regions. 

d. The whole spine was tender in fifteen cases, and so extensive was 
the hyperesthesia that it was scarcely possible to press upon the most 
limited spot without producing pain. Of these cases the most promi- 
nent symptom in three was epilepsy, in one paralysis, sometimes of 
the upper and sometimes of the lower extremities, and in three con- 
tractions of the limbs. Neuralgic pains, either in the scalp, face, 
neck, chest, upper extremities, abdomen, and lower extremities, were 
present in every case, according to the part most severely affected 
for the time being. The heart was disordered in five cases, the 
stomach in ten, in three there was difficulty of swallowing, from 
alternating paralysis, and spasm of the muscles of the larynx, and 
in two aphonia. 

Causes. — The most powerful predisposing cause is sex. Of the one 
hundred and fifty-six cases, one hundred and forty were females. Age 
is likewise influential in determining to the disorder. Of one hundred 
and thirty-seven cases in which I have recorded the age, seventy-two 
were between fifteen and twenty-five, thirty-two between twenty-five 
and thirty-five, fifteen under fifteen, and eighteen over thirty-five. The 
period of life between fifteen and twenty-five is therefore that at which 
spinal irritation is most apt to occur. 

Hereditary influence was ascertained to exist in thirty cases. 

The exciting cause of spinal irritation is not always easy to ascer- 
tain. In thirty out of one hundred and thirty-seven cases I could not, 
by the most careful inquiry, find any circumstance likely to have giveu 
it origin. In twenty-one it was manifestly produced by blows, falls, or 
strains, in twelve it was obviously caused by sexual excesses, and four 



388 DISEASES OF TIIE SPINAL CORD. 

by onanism. In ten there was reason to ascribe it to anxiety and grief, 
in two to excessive mental exertion, in twenty-one to insufficient phys- 
ical exercise, in fourteen to innutritious and insufficient food, in three 
to over-indulgence in alcoholic liquors, and in one to the use of opium. 
In the remaining nineteen cases it followed exhausting diseases, such 
as typhoid, scarlet, and intermittent fever, dysentery, and diphtheria, 
and was probably directly the result of their influence. 

Abnormal positions of the uterus and prolonged irritation of the 
ovaries sometimes occur in spinal irritation. 

It may also be caused by obliteration of the aorta or spinal vessels, 
by tumors, thrombosis, or embolism, by haemorrhage from vessels in re- 
lation with those of the cord, or by exposure to severe cold. 

In general terms, it may be said that any cause capable of reducing 
the powers of the system may produce spinal irritation. 

Morbid Anatomy and Pathology. — I have already stated it as my 
opinion that the essential condition of spinal irritation is anaemia of the 
posterior columns of the cord. Other writers have ascribed it to in- 
flammation, congestion, hysteria, and numerous other factors. The 
reasons which have induced me to arrive at this conclusion are briefly 
as follows : Owing to the fact that spinal irritation is not per se a fatal 
disease, we rarely have the opportunity to verify any views we may 
hold in regard to its pathology. In the few cases in which post-mortem 
examinations were made, nothing abnormal was found, a circumstance, 
however, far more compatible with the idea I have expressed than with 
any other : 

1. It is a well-recognized fact that irritation is often a result of a 
deficient supply or a poor quality of blood. Thus headaches are fre- 
quently caused by cerebral anaemia, and are promptly relieved by in- 
creasing the amount of blood in the cerebral blood-vessels. Irritability 
of the mind is also a constant accompaniment. A feebly-nourished 
stomach rejects food, and is the seat of pain. An anaemic heart beats 
with great rapidity, weak muscles are affected with tremor, and an ex- 
hausted generative system is brought into a state of unnatural erethism 
by the slightest kind of excitation. Analogy, therefore, supports the 
theory I have suggested. 

2. The diagnosis of diseases of the spinal cord has become so perfect 
that we are able to distinguish congestion, meningitis, myelitis, soften- 
ing, tumors, etc., by their symptoms and by the means of research at 
our command. We see, therefore, that the morbid phenomena which 
result from such conditions are not such as we now class under the head 
of spinal irritation. This division of the subject will be more fully con- 
sidered under the head of diagnosis. 

3. I have repeatedly ascertained, by actual experience, that those 
agents which are known to diminish the amount of blood in the spinal 
vessels invariably increase the severity of the symptoms due to spinal 



SPINAL ANJEMIA. 389 

irritation, while they are as effectually lessened in intensity by remedies 
which tend to produce spinal hyperemia. 

4. The general condition of patients the subjects of spinal irritatioD 
is always below par, and the exciting causes are all such as tend to the 
production of asthenia. 

5. The character of the symptoms points decidedly to the greater, 
and at times sole implication of the posterior columns. There are cases 
of the disorder in which there is no derangement of motility in any part 
of the body, and in all cases aberrations of sensibility are the prominent 
features. Moreover, the viscera are generally affected in their func- 
tions, a circumstance of itself strongly indicative of the situation of the 
lesion in the posterior columns. 

These circumstances, I think, go very far toward confirming the 
view I have expressed, that in spinal irritation the vessels of the cord, 
especially those of the posterior columns, contain less blood, and that 
this fluid is inferior in quality to that of the organ when it is in a 
healthy condition. Now that the function of the sympathetic nerve, as 
regards its action in regulating the calibre of the blood-vessels, is so 
satisfactorily proven, we can partially understand how local congestions 
and ansemias may be superinduced. It is probable, therefore, that the 
original disturbance in many cases of spinal irritation resides in the 
sympathetic system, and the intimate anatomical relations existing be- 
tween the two nervous centres are strongly in favor of this suggestion. 

On the other hand, many of the phenomena of spinal irritation point 
strongly to the secondary involvement of the sympathetic system. It 
is thus that the visceral disturbances which form such prominent feat- 
ures are mainly to be explained. 

The pathology of several others of the more striking symptoms of 
spinal irritation has been a subject of frequent discussion, but at the 
present day presents no difficulties. Thus the excitation of pain in the 
tissues to which the cutaneous nerves are distributed results from the 
law that irritation at a nervous centre induces pain at the points in 
which the nerves arising from that centre end. Each compound spinal 
nerve sends a twig to the skin contiguous to it, and these twigs termi- 
nate immediately over the spinous processes. Now, whenever an irrita- 
tion is thus transmitted to the periphery, it may be reflected back to the 
centre whence it came, by local irritations. Thus a patient is suffering 
from chronic inflammation of the spinal cord, and in consequence has 
pain and muscular spasms in his lower extremities. An irritation ap- 
plied directly to the cord increases the pain and spasms ; an irritation 
applied to the lower extremities augments the pain in the cord, and 
may induce pain and spasms in distant parts of the body. Herce it is 
that pressure on the skin over the spinous processes not only causes 
cutaneous pain, but also gives rise to spinal pain, and neuralgic sensa- 
tions in those nerves which come from the irritated part of the cord. 



390 DISEASES OF THE SPINAL CORD. 

The pain existing in the cord is aggravated by percussion or mus- 
cular action. The spinal cord, it is true, is inclosed in a strong and 
thick, bony canal, which, however, is entirely filled by its contents. A 
blow, therefore, on the exterior of the column causes a vibration, which 
is propagated through the bony structure to the cord and its mem- 
branes. If this blow be very violent, the concussion may be such as to 
inflict irreparable damage on the cord. When any portion of the cord 
is in a state of irritation, a very light blow upon the spinous processes, 
over the disordered part, will cause severe pain, or notably add to that 
already present. The vertebral column is flexible, and therefore mus- 
cular action may, by producing deviations from the ordinary line fol- 
lowed, occasion pressure, and, in the abnormal condition of the cord, 
excite pain. 

Diagnosis. — Recollecting that no case is to be regarded as one of 
spinal irritation which is not characterized by spinal tenderness, we 
have our diagnostic inquiries limited to the distinguishing of spinal 
irritation from other spinal affections. It is certainly true that the 
distinction has often been overlooked, and that at times there is a real 
difficulty in forming a correct judgment. Nevertheless, by carefully 
estimating all the circumstances, permanent errors of diagnosis are not 
likely to occur. 

There are three diseases of the spinal cord which may in their ear- 
lier stages be confounded with simple spinal irritation. These are 
chronic myelitis, meningitis, and congestion. As the treatment of these 
affections is in many respects the exact reverse of that proper for spinal 
irritation, and as they are of far more serious character, it is important 
to make as early and as correct a discrimination as possible. 

In both spinal irritation and myelitis there is tenderness over some 
part of the vertebral column, which tenderness is increased by pressure, 
but this tenderness is never due to hypersesthesia of the skin, whereas 
in spinal irritation it often is. 

In spinal irritation there is never, so far as my experience goes, 
anaesthesia, whereas this is a constant accompaniment of myelitis. 

The contractions which take place in some cases of spinal irritation 
are painless, while those due to myelitis are attended with great suffer- 
ing. 

In myelitis there is a sensation as if a tight cord were tied around 
the body at the upper limit of the paralysis, a sensation w^hich is absent 
in spinal irritation. It is true that Mr. Teale has described several 
cases which he classed as spinal irritation and in which the sensation of 
constriction was present, but careful examination of the histories leaves 
scarcely a doubt that these were really cases of myelitis. 

The bladder is never paralyzed in spinal irritation, whereas in mye- 
litis it generally is, if the inflammation be located in the lower dorsal 
region of the cord. The same is true of the sphincter ani. Myelitis is 



SPINAL ANAEMIA. » 391 

always productive of paralysis, and there is always more or less atrophy 
of the paralyzed muscles.. Spinal irritation seldom gives rise to paraly- 
sis, which, when it does result, is always incomplete, and is never pro- 
ductive of atrophy. 

The progress of myelitis is generally, unless arrested by appropriate 
treatment, toward a worse condition, whereas no such tendency is 
manifested by spinal irritation. 

In myelitis, after the first ten days, electrical "reactions of degen- 
eration " can always be obtained in paralyzed muscles, while in spinal 
irritation the reactions are normal. 

From spinal meningitis, spinal irritation is distinguished by the cir- 
cumstances that in the former disease there are constant painful spasms 
of the muscles of the back, pain in the cord, and no spinal tenderness 
increased by pressure. 

From congestion of the spinal cord and its membranes, spinal irri- 
tation is sufficiently distinguished by the facts that there is generally 
little or no pain in the cord in the first-named affection, and no spinal 
tenderness. In congestion, likewise, the paralysis and other symptoms 
are always worse after the patient has been lying down, while in spinal 
irritation the recumbent position always alleviates the condition. 

Another means, which in doubtful cases will invariably lead to a 
correct diagnosis, is afforded by the known effects of certain medicines. 
Thus spinal irritation is, as I have several times ascertained, made 
worse by the administration of ergot, while, each one of the other dis- 
eases I have named is alleviated. The reverse is true of strychnia, 
which in all cases aggravates the symptoms of myelitis, meningitis, 
or congestion, while it is an efficient means of cure in spinal irrita- 
tion. An hypodermic injection of the thirtieth of a grain is suffi- 
cient to settle the matter in cases where the diagnosis is of difficult 
formation. 

The flatulence, eructations, and vomiting, are very symptomatic 
of spinal irritation, while they are rarely phenomena of either of the 
other affections. 

One other disease is liable to be confounded with spinal irritation, 
and that is angular curvature, in which there is spinal tenderness in- 
creased by pressure. The facts, however, that strumous disease of the 
vertebrae generally occurs in children, that the scrofulous diathesis is 
always present, that an angular prominence can be detected by careful 
examination, that the paralysis progressively becomes more profound, 
that the constitutional effects are more severe, are sufficient, even in 
doubtful cases, to guide to a correct diagnosis. 

Prognosis. — The prognosis in cases of spinal irritation is generally 
favorable. In fact, so far as my experience extends, I have never seen 
a case which entirely resisted treatment, and very few in which a cure 
was not ultimately effected. When remedies suitable for the difficulty 



392 DISEASES OF THE SPINAL CORD. 

do not prove successful, it is because the patient does not steadfastly- 
perse vere in their use. Of the one hundred and fifty-six cases form- 
ing the basis of this chapter, one hundred and thirty-three were 
thoroughly cured, ten were lost sight of soon after treatment was 
commenced, but were materially improved, and thirteen were relieved 
for the time being, but continued to have relapses. 

Treatment. — The principles of treatment applicable to spinal irrita- 
tion are four : 1. To remove the cause. 2. To improve the general 
tone of the system. 3. To increase the amount of blood in the spinal 
cord, and improve the nutrition of this organ. 4. To set up a counter- 
irritant action in the vicinity of the disordered region of the cord. 

In regard to the first indication, I have nothing special to say. The 
cause once ascertained, common-sense would dictate its removal as 
speedily and as effectually as possible, by the proper means according 
to its character. 

The second indication is to be met by tonics, such as quinine and 
iron, and especially stimulants judiciously administered. I am as well 
convinced of the general applicability of alcohol in some form, in the 
treatment of spinal irritation, as I am of any thing. Whiskey, brandy, 
and rum, are to be preferred on account of their less liability to dis- 
agree with the stomach, and as containing a greater percentage of 
alcohol than vinous or malt liquors. Among the tonics the prepara- 
tions of zinc are valuable, and I think the oxide is to be preferred. 
Cod-liver oil is also of great service. 

The third indication is easily fulfilled by strychnia, phosphorus, phos- 
phoric acid, and opium. The two first-named remedies may be very 
satisfactorily combined in a pill containing half a grain of extract of 
nux-vomica and the tenth of a grain of the phosphide of zinc, which 
may be given three times a day. Strychnia may also be given by solu- 
tion of the sulphate in dilute phosphoric acid, and in doses of about the 
thirty-second of a grain to half a drachm of the acid. The beneficial 
effects of these remedies are perceived in a few days. Opium is espe- 
cially useful in those cases in which there are contractions of the limbs, 
and here its action is, of course, not solely that of an agent increasing 
the amount of blood in the cord. I prefer to give it either in the form 
of suppositories, composed each of half a grain of the aqueous extract 
and a sufficient quantity of the butter of cacao, or by hypodermic injec- 
tion of morphia. I have frequently seen contractions, which had per- 
sisted with obstinacy for several weeks, relax in a few minutes under the 
influence of opium thus administered. 

The application of hot water to the spine is also an admirable adju- 
vant. It should be used as hot as can be borne. Nothing is better for 
the purpose than Dr. Chapman's India-rubber bags. 

The fourth indication is one of great importance, and, when properly 
carried into effect, a cure will often result in slight cases without any 



SPIXAL AN.EMIA. 393 

other means of treatment being employed. Of counter-irritants my 
experience leads me decidedly to the employment of blisters in prefer- 
ence to any others. They should be applied to the skin, immediately 
over the painful part of the spine, and should be renewed as often as 
may be necessary. Dry cups almost always do good. Leeches, or any 
other means for the abstraction of blood, are, according to my experi- 
ence, always prejudicial. 

Electricity, in whatever form it may be applied to the skin, acts 
only as a counter-irritant. It certainly has great power in the dis- 
ease under consideration. A seance should be given every day, and 
should not last longer than ten or fifteen minutes. In every way 
the statical form is to be preferred. The patient should be seated on 
the insulated stool, and then sparks should be drawn with the large 
brass ball-electrode from the part of the skin in which the morbid, con- 
dition exists. The clothing should not be removed. It often happens 
that all spinal tenderness disappears after two or three applications. 
If the galvanic or faradaic current be employed, the electrodes — wet 
sponges or wire brushes — should be drawn slowly over the skin of the 
affected part, and the current should be strong enough in either case 
to redden the skin and to cause considerable pain. 

Latterly I have made use of percussion with decided beneficial 
results. A stick somewhat like a crochet-needle is run through an 
India-rubber ball about two inches in diameter, and with this instru- 
ment the skin is pounded for five minutes or so night and morning. 
The painful parts should not be spared. Tolerance is generally estab- 
lished in a few days, and then the patient takes pleasure in the pounding. 

Besides these therapeutical means, there are others of a more strictly 
hygienic character, which cannot be overlooked. Thus the food should 
be of a highly-nutritious character, moderate physical exercise should 
be taken, and as much time as possible should be spent in the open air. 

Patients almost always feel more comfortable in the recumbent po- 
sition than any other, because thereby the blood is allowed to settle in 
the spinal vessels. They should not therefore be prevented lying down 
during the greater part of the day, but at the same time they should be 
encouraged to take exercise, and especially so when there is any loss 
of power in the lower extremities. The induced or faradaic current is 
almost always of service, when applied to the affected muscles, and the 
direct is of great efficacy when passed through neuralgic nervous trunks. 

In illustration of the views inculcated in this chapter, I append the 
following details of cases : 

Case I. Irritation of the Cervical Region of the Spinal Cord. — 
Mrs. J. S. consulted me, May 7, 1868, for what she had been informed 
was a cerebral disorder. The patient was thirty-eight years of age, had 
had five children, and had always enjoyed good health till two years 
previously, when she had been thrown from her carriage. She was not 



394 DISEASES OF THE SPINAL CORD. 

stunned or otherwise seriously injured. Soon after the accident she 
noticed a rumbling noise in one ear, and in a few days subsequently the 
other ear became similarly affected. About the same time there were 
flashes of light before the eyes, and a dull, heavy pain in this point of 
the head. Vertigo was also frequently present. There was insomnia, 
and when she did sleep she was very apt to be attacked with night- 
mare. 

These symptoms continued to annoy her for several months, with- 
out, however, compelling her to seek for medical advice, until at last 
she had a seizure which was certainly epileptic in its character. This was 
followed with disturbance of vision, and intense neuralgia of the fifth 
pair of nerves. She now placed herself under the charge of a physician 
in a neighboring city, where she was then residing, who diagnosticated 
a tumor of the brain, and gave an unfavorable opinion as to the ulti- 
mate result. He, however, advised the use of iodide of potassium. 
She took this in large doses faithfully for three months — during which 
period she had two more epileptic attacks — without perceiving any ben- 
efit, and then she went to Europe. While there she consulted a num- 
ber of physicians and surgeons of eminence, all of whom gave a very 
guarded prognosis. By the advice of several of these she took the 
bromide of potassium, with, at first, some advantage, but this was event- 
ually lost, and her symptoms became as severe as before. She had 
several epileptic paroxysms during the four months she was taking the 
bromide. Finally, she traveled through Germany and Italy, and, still 
obtaining no relief, returned home. I saw her a few days after her 
arrival. She was then suffering from facial neuralgia, excessive tender- 
ness of the scalp, so that she could not have her hair brushed without 
enduring great pain, obscureness of vision, pain in the eyeballs, redness 
of the conjunctivae, vertigo almost constantly, great mental irritability, 
amounting at times to positive insanity ; wakefulness, nightmare, and 
contraction of the fingers, the nails being strongly pressed against the 
palm of the hand. 

Ophthalmoscopic examination showed dilatation of the retinal ves- 
sels, arterial and venous pulsation, and congestion of the optic disks 
of both eyes. The pupils of both eyes were contracted. 

Perhaps I should not have suspected any spinal disorder, if she had 
not herself called my attention to a pain which she said she constantly 
felt between the shoulders. I therefore examined the upper part of 
the spine very carefully, and found deep-seated pain developed by per- 
cussion over the seventh cervical vertebra, and great hyperesthesia of 
the skin in the same region. Her symptoms were not those in the least 
indicative of congestion of the cord or its membranes, of meningitis, or 
myelitis, and the apparent severity of the cerebral symptoms, and the 
general good condition of her mind and sensorial and motor functions, 
were so incompatible, that I could not, upon reflection, bring myself to 



SPINAL ANEMIA. 395 

the belief that she was affected with any organic disease of the brain. 
My inquiries and examinations all led me to the conclusion that she was 
laboring under spinal irritation of the lower cervical region. 

I therefore prescribed for her five drops of the phosphorated oil 
three times a day, applied a blister to the painful spot, and daily 
passed the direct galvanic current through the cord, by applying the 
negative pole to the fifth cervical, and the positive to the sixth dorsal. 
My object was, not only to improve the nutrition of the cord, but also, 
by irritation of the sympathetic, to contract the vessels of the brain. 
Budge and Waller had shown, several years previously, that,, when that 
portion of the spinal cord situated between the seventh cervical and 
sixth dorsal vertebrae is acted upon by the galvanic current, the pupils 
are dilated. Now, dilatation of the pupils is produced by excitation of 
the sympathetic, and excitation of the sympathetic, within the limits 
mentioned, likewise causes contraction of the vessels of the brain, as 
can readily be seen by ophthalmoscopic examination while the current 
is passing. 

Under the influence of this treatment the amendment was rapid, 
and at the end of three months she was entirely cured. It was neces- 
sary, however, to apply eleven blisters. 

Case II. Irritation of the Cervical Region of the Cord. — M. S., a 
gentleman of sedentary habits, consulted me, August, 1867, for intense 
headache and facial neuralgia, with which he had suffered for several 
months. The disease had come on gradually, and, although now never 
entirely absent, was paroxysmal in its character, being more severe at 
night than through the day. The external pain followed the course of 
the fifth pair of nerves through all its branches ; the internal was fixed 
in the posterior part of the head, and was evidently due to cerebral 
anasmia, as it was relieved by stimulants and by holding the head in a de- 
pendent position. Vertigo was frequently present, and the disposition to 
sleep was excessive, though, owing to the pain, it could not be indulged 
in for more than a few minutes at a time. Nausea was occasionally a 
symptom, but never to the extent of being followed by vomiting. 

On examining the spine of this gentleman, I found tenderness over 
the fourth and seventh cervical vertebras. Two blisters were at once 
applied, and Aitken's syrup of the phosphate of iron, quinine, and 
strychnia, administered. From the first, improvement was manifested, 
and in less than a month the cure was complete. 

Case III. Irritation of the Dorsal Region of the Spinal Cord. — 
Mra. J. B., aged twenty-four, consulted me, March, 1868, for obstinate 
vomiting, and neuralgic pains in the left breast. She was thin, pale, 
and anaemic, and had suffered for over a year. She also complained of 
a dull, aching pain in the middle of the back, which was increased by 
even moderate physical exercise. The vomiting took place regularly 
after every meal, and even water was at once thrown up. She was 



DISEASES OF THE SPINAL CORD. 

under the impression that the disorder was the result of exposure for 
several hours to very severe cold while in an open boat. 

Recognizing, at once, the fact that the main difficulty lay in the 
cord, I carefully examined the whole spine, and found excessive tender- 
ness over the spinous processes of the sixth, seventh, and eighth dorsal 
vertebrae. There was also deep-seated spinal pain developed by percus- 
sion. 

I ordered the application of a blister, and the internal use of small 
quantities, frequently repeated, of milk-punch (one ounce of brandy to 
three of milk). The first wineglassful was at once rejected, and so 
was a tablespoonful which she took half an hour subsequently. I then 
reduced the quantity to a teaspoonful every half -hour. This was re- 
tained, and was the first nutriment of any kind which, for nearly eleven 
months, had not been rejected wholly or in part. 

The next day I found that the blister had drawn well, and that the 
nausea and vomiting were greatly diminished, as were likewise the 
neuralgic pains. A teaspoonful of the following mixture was then 
directed to be taken three times a day, immediately after meals : $. 
Strychnise sulph., gr. j; ferri pyrophosph., quinise sulph., aa 3 ss ; acid, 
phosph. dil., syrupi zingiberis, aa § ij. M. ft. mist. The milk-punch 
was still continued, but, in treble the dose, less frequently given. 

Gradually all the symptoms decreased in violence, and at the end of 
two weeks she was enabled to retain a moderate quantity of food at 
each meal. Any excess was still, however, followed by vomiting. She 
had increased five pounds in weight, and was greatly improved in per- 
sonal appearance. 

In two months she had gained twenty-one pounds, and was as well 
as she had ever been in her life. The spinal tenderness had entirely 
disappeared ; seven blisters were applied in all. 

Case IV. Irritation of the Dorsal Region of the Spinal Cord.— 
Mrs. W. had for more than three years suffered from spasmodic move- 
ments of the upper extremities, not distinguishable from those of true 
chorea, which occasionally were followed by contractions of the flexors 
of the wrists and fingers. There were also infra-mammary pain, eructa- 
tions, and vomiting. When she came under my care, June 22, 1869, 
she was reduced to almost a skeleton, and was suffering, in addition to 
the symptoms above mentioned, from acute pain in the back. This 
pain she informed me had not been ordinarily very severe, but was, 
nevertheless, constantly present. On examination I found tenderness 
over the first, second, and third dorsal vertebras. I at once applied the 
constant galvanic current in a manner already described, and continued 
it for five minutes, with the effect of mitigating the pain in the spine 
and the nausea. The ensuing day I repeated the application, and in 
addition prescribed the mixture given in Case III. She retained it on 
her stomach, as she did the food which she ate that day. Brandy in 



SPINAL ANAEMIA. 397 

ounce-doses was given with her lunch and dinner. The galvanism was 
continued daily for eighteen days, at the end of which time she was free 
from pain, from the spasms, and from the vomiting. Her appearance 
was immensely improved, and she had increased seven pounds in weight. 
The galvanism was now discontinued, but the strychnia mixture and 
the brandy were persevered with for over a month longer. She was then 
well. 

Case Y. Irritation of the Lumbar Region of the Spinal Cord. — 
E. T., an unmarried lady, aged twenty-nine, consulted me, August, 1869, 
for paralysis of the lower extremities, attended with spinal tenderness 
and abdominal pains. She had been treated for inflammation of the 
spinal cord, had been cupped, leeched, and had had an issue made over 
the seat of the pain. 

When I first saw her she was unable to walk, having been in this 
condition for several months. As she sat in her chair, she could readi- 
ly move her legs in any desired direction, but to bear her weight upon 
them was an utter impossibility. There was no alteration of sensibility. 
Her general appearance was not anaemic, nor was she in the least degree 
hysterical. Upon careful examination, I was unable to find any reason 
to induce the belief that she was laboring under spinal congestion, 
meningitis, or myelitis, or that there was softening of, or pressure upon, 
the cord. I, however, discovered great tenderness over the first and 
second lumbar vertebrae, and found that strong pressure in this region 
induced deep-seated spinal pain and sharp neuralgic sensations along 
the course of the crural nerves. 

Regarding the case as one of pure spinal irritation, I applied the 
constant galvanic current to the back every alternate day, and adminis- 
tered the following prescription : 3 • Zinci phosphidi, gr. iij ; ext. nucis 
vom.j gr. xv. M. ft. in pil. no. xxx. Dose, one three times a day. I 
likewise directed the application, to the painful part of the spine, of 
flannel, wrung out of spirits of turpentine, to be continued daily till 
redness and decided smarting were produced. A full and nutritious 
diet, with ale, was enjoined. Under this treatment she improved so 
rapidly in every respect that in twenty-three days she was able to walk 
with a cane, and in a few days more than a month was well, being in as 
good health, according to her own report, as she had ever enjoyed in 
her life. 

ANEMIA OF THE ANTEEO-LATEEAL COLUMNS OF THE COED. 

The phenomena which in my opinion are the result of an anaemic 
ccndition of the antero-lateral columns of the spinal cord have hitherto 
been classed under the heads of spinal paresis, functional paralysis, 
reflex paralysis, inhibitory paralysis, paralysis from peripheral irritation, 
etc. Several of these names are applied with reference to the causes, 
others with reference to the symptoms, but none to the lesion. 



398 DISEASES OF THE SPINAL CORD. 

Symptoms. — The most prominent symptom of anemia of the ante- 
rolateral columns of the spinal cord is paralysis of motion in those 
parts of the body which derive their nerves from the affected portion 
of the cord, and in many cases of those below the seat of the lesion. 
This paralysis is incomplete, the patient, if the lower extremities are 
affected, being able to walk, though he docs so with difficulty. It is 
noticed, too, that some muscles are more apt to be paralyzed than 
others, the tibialis anticus and the peroneal group rarely escaping. 

In the great majority of cases the paralysis is confined to the lower 
extremities, constituting paraplegia. The reason for this is, that the 
anaemic condition of the cord which causes the paralysis is more fre- 
quently excited by irritation transmitted from the genito-urinary and 
digestive organs than from any others. 

Spasmodic contractions of the paralyzed muscles are not often met 
with, though occasionally there are slight twitchings, fibrillary in their 
character. 

It is rarely the case that the paralysis extends, as it does in that 
which results from congestion of the cord. The affection usually super- 
venes suddenly, and is about as severe in the beginning as at any sub- 
sequent period. 

The bladder and rectum are very rarely involved as a consequence 
of the spinal lesion, though disease of either of these organs often 
causes anaemia of the antero-lateral columns of the cord. In a few 
cases, however, -I have witnessed both paralysis of the bladder and of 
the sphincter coming on late in the course of the disease, and evidently 
dependent on it. 

Electro-muscular irritability is rarely impaired. Reflex excitability 
is also generally unaffected. In the worst cases, tickling the sole of 
the foot will cause the leg to be drawn up, even against the volition of 
the patient. 

Disorders of sensibility are not prominent features in anaemia of the 
antero-lateral columns of the spinal cord. Locally there is very rarely 
pain, and in the paralyzed parts there is neither anaesthesia, hyperaes- 
thesia, nor abnormal sensations of any kind. There is never, in the un- 
complicated affection, the sensation of constriction about any part of 
the body. The stomach and bowels are not often affected, unless there 
is at the same time some degree of anaemia of the posterior columns. 
But in one very interesting case, occurring in a lady of this city, and 
produced by exposure to extreme cold while crossing to Governor's 
Island in an open boat, there were vomiting every time food was taken 
into the stomach, and the most obstinate constipation I have ever wit- 
nessed. It very frequently happened that this lady had no operation 
from her bowels for over a month. 

Causes. — Anaemia of the antero-lateral columns of the spinal cord 
may be produced by any cause capable of interrupting the flow of blood 



SPINAL ANJEMIA. 399 

to the region in question, of lessening the calibre of its autocthonous 
arteries, or of so lowering the quality of the blood as to unfit it for the 
purposes of nutrition. 

Thus it may be caused — though not without the implication of the 
posterior columns — by abdominal tumors compressing the aorta, or by 
disease of this vessel, leading to partial or complete obliteration ; by 
thrombosis or embolism of the spinal arteries ; or by direct loss of blood 
from vessels supplying the cord, or deriving their blood from the spinal 
vessels. 

The calibre of the intra-spinal vessels may be lessened through the 
influence of extreme cold, and ansemia of the antero-lateral columns 
thus be induced. Several cases of this kind have come under my care, in 
which paraplegia has supervened suddenly during or after exposure to 
very low temperature, especially when combined with a moist state of 
the atmosphere. Lying on damp ground has caused it in a number of 
instances. 

It not unfrequently follows exhausting diseases of various kinds: I 
have known it to supervene on dysentery, diarrhoea, cholera, typhoid 
fever, typhus, diphtheria, and several other affections. 

But the most common cause of the disorder is undoubtedly periph- 
eral irritation, and this is very frequently an affection of the genito- 
urinary organs. My friend Dr. S. Weir Mitchell a has written very ex- 
haustively on this subject, and has shown the relation which exists 
between the different paralyses now usually called reflex, and injuries 
of nerves. Under the head of pathology I shall have occasion to return 
to Dr. Mitchell's valuable contributions. 

Diagnosis. — Anaemia of the antero-lateral columns of the cord is dis- 
tinguished from congestion by the facts that the symptoms are miti- 
gated by the recumbent position instead of being increased in violence, 
as in the latter affection ; that the paralysis shows no tendency to be- 
come more severe, and that, when the bladder or rectum is involved, 
the derangement of either viscus precedes the paralysis. 

From anaemia of the posterior columns, it is diagnosticated by the 
fact that the more obvious symptoms are related to motility, sensibility 
not being involved, while in the former the reverse is the case. 

The diagnosis from myelitis will be pointed out when inflammation 
of the cord is under consideration. 

Prognosis. — The probability of a favorable termination is great. In 
fact, no affection of the cord is so susceptible of cure when there is no 
mechanical obstruction in the aorta or spinal arteries. But this opin- 
ion is expressed with the understanding that the cause must first be 

i Circular No. 6, 1864, Surgeon-General's Office. "Reflex Paralysis," by Drs. Mitch- 
ell, Morehouse, and Keen. Also " Wounds and Injuries of Nerves by the same," Phil- 
adelphia, 1864. Also "Paralysis from Peripheral Irritation," by Dr. Mitchell, New York 
Medical Journal, February, 1866. 



400 DISEASES OF THE SPINAL CORD. 

removed. So long as this continues in action, anaemia cf the antero- 
lateral columns of the cord is a very obstinate affection. When the arte- 
ries are obstructed, then, as in the brain under like conditions, softening 
of the cord may take place. 

Morbid Anatomy and Pathology. — Post-mortem examination, of per- 
sons who have suffered with symptoms indicative of what I consider to 
be anaemia of the antero-lateral columns of the cord, does not reveal the 
existence of any material spinal lesion. The reason for this is, that anae- 
mia of the cord is, in the nature of things, a very difficult disease to 
detect, and cannot be definitely made out, unless the capillaries are 
measured under the microscope. 

But it is this very absence of obvious lesions which indicates very 
positively the existence of anaemia, and the character of the symptoms 
shows that the antero-lateral columns are its seat. 

Several varieties of paralysis result from anaemia of the antero-lat- 
eral columns. Classing these as Mitchell * has done, from their apparent 
causes, we find that there are — 

1. Paralyses arising during disease of the genito-urinary organs. 

2. Those which occur during or just after dysenteries, diarrhoeas, 
super-purgation, or in connection with worms. 

3. Such as arise during or after pneumonia or pleurisy. 

4. Such as are seemingly brought on by dentition. 

5. The paralysis of diphtheria, fevers, and eruptive disorders. 

6. Such as seems to be occasioned by cold, or by cold and moisture. 

7. Paralysis due to external injury. 
To this list may be added — 

8. Paralysis resulting from certain medicines and drugs. 

9. Paralysis due to great emotional disturbance. 

Many cases of each of these varieties of paralysis have come under 
my notice, and there are few medical practitioners who have not wit- 
nessed instances referable to one or more of the foregoing categories. 
The principal theories of their immediate cause are — 

1. That of Mr. Stanley, 2 by which certain varieties of paralysis are 
attributed to the transmissal of an irritation from a diseased organ to 
the spinal cord, whence it is reflected to the muscles as paralysis. 

This is no explanation at all, and leaves the condition of the cord 
out of consideration. There is no proof whatever that an irritation can, 
without causing change in the structure of the nervous centre, induce 
either paralysis of motion or of sensation. 

2. That of Dr. Brown -Sequard, 3 which ascribes the affections in 
1 " Paralysis from Peripheral Irritation, with Eeports of Cases," New York Medical 

Journal, February, 1866, p. 323. 

* " On Irritation of the Spinal Cord and its Nerves in Connection with Disease of the 
Kidneys," " Medico-Chirurgical Transactions," vol. xviii., p. 260. 

8 Lectures on the " Diagnosis and Treatment of the Principal Forms of Paralysis of 
the Lower Extremities," Philadelphia, 1861. 



SPINAL AN.EMIA. 401 

question to a lesion of the cord, consisting in a spasm of the spina] 
vessels by which their calibre is diminished. This spasm is, according 
to this eminent neurologist, the result of a peripheral irritation trans- 
mitted through the nerves coming from a diseased organ or part of the 
body, to the vaso-motor nerves of the portion of the cord giving origin 
to these nerves. 

This was, so far as I have been able to ascertain, the first attempt 
to designate the character of the lesion, which, as will be at once per- 
ceived, is anaemia. That anaemia can be induced by peripheral irritation 
is, I think, well established. But though this theory accounts for many 
cases of spinal paralysis, such as are now under notice, it will not em- 
brace all, for we may have anaemia and consequent loss of motor power 
resulting from other causes than irritation. Moreover, Dr. Brown- 
Sequard did not fix the lesion in the antero-lateral columns, nor associ- 
ate the symptoms with any derangement in the structure of this region 
of the cord. 

3. Dr. Mitchell, in the paper to which I have already referred, divides 
the several kinds of paralysis mentioned into three classes: those which 
are asserted to be due to disease of the genito -urinary system, a cause 
which he denies in toto / those which are said to be produced by periph- 
eral irritation of the intestinal canal, an influence which he also in great 
part denies; and those which follow wounds and injuries of nerves. 

Dr. Mitchell rejects altogether the reflex theory of Dr. Brown- 
Sequard, and says: 

" If I were now to sum up the probabilities in the way of causation 
of palsies peripherally induced, I should be disposed to refer some cases 
to exhaustion from too constant or excessive exercise of normal func- 
tions, and others to irritation from disease or injury, and to consequent 
exhaustion of the centres; while, as regards the intervention of vascular 
agency, I should reject the idea of prolonged vasal spasm, and consider 
it possible that in some instances over-excitation might result in dila- 
tation of the vessels, in which case some material lesion would surely 
result if the condition in question were of long continuance." 

While not prepared to accept Dr. Mitchell's views in their entirety, 
they are, in my opinion, perfectly in accordance with the doctrine of 
anaemia of the antero-lateral columns. As to whether this anaemia is 
the result of spasm of the spinal vessels, or exhaustion, is a question 
which, for the present at least, is not definitely settled. My own opin- 
ion is that paralyses of apparently peripheral origin are referable to 
anaemia, produced in some cases by vaso-motor spasm, and in others by 
nervous exhaustion. 

The experiments of Kussmaul and Tenner * are perfectly conclusive 
as to the effects of cutting off the supply of blood to the spinal cord. 

• * "The Nature and Origin of Epileptiform Convulsions caused by Profuse Bleeding 
etc." New Sydenham Society Translations, London, 1859, p. 53, et seq. 
27 



402 DISEASES OF THE SPINAL CORD. 

These observers compressed the aorta in rabbits so completely that not 
a drop of blood could reach the spinal cord below the point of occlusion. 
The consequence was, that there was complete paralysis of all the mus- 
cles receiving their nervous influence from the anaemic portion of the 
cord. The possibility, therefore, of spinal anaemia producing paralysis, 
is beyond doubt. In these experiments, however, the blood was of 
course shut off from both the anterior and posterior columns, and there- 
fore the phenomena were not those of simple motor paralysis. 

M. Vulpian x has recently discussed, very thoroughly, the several 
questions connected with the pathology of reflex paralysis. By an 
experiment, which consisted in faradizing a communicating branch of 
the intra-thoracic chain of ganglia, a decided contraction was seen to 
take place in the vessels of the spinal cord at the point of origin of the 
intercostal nerve in relation with the irritated branch. When the 
faradization was intermitted, the vessels returned to their former size — 
or, perhaps, even became a little larger than was natural. This experi- 
ment was therefore followed by a result similar to that recorded by 
Brown-Sequard, who says: 2 " A contraction of blood-vessels in the spinal 
cord I have seen (in the vessels of the pia mater) take place under my 
eyes, when a tightened ligature was applied on the hilus of the kidney, 
irritating the renal nerves, or when a similar operation was performed 
on the blood-vessels and nerves of the suprarenal capsules. Generally 
in these cases the contraction is much more evident on the side of the 
cord corresponding with the side of the irritated nerves, which fact is 
in harmony with another and not rare one, observed first by Combaire 
(as regards the kidney), and often seen by me after the extirpation of 
one kidney, or one suprarenal capsule — i. e., paralysis of the corre- 
sponding lower limb." 

M. Vulpian admits that anaemia of the spinal cord causes with 
great rapidity the abolition of the medullary functions. The fact is 
established by experiments consisting in the obliteration of the spinal 
vessels by substances injected into them. Thus Flourens, 3 many years 
ago, injected the powder of lycopodium into the crural artery of a dog, 
taking care to throw the substance with some force into the artery 
against the current of the circulation, so that it entered the abdominal 
aorta and was distributed to the spinal vessels. The powder occluded the 
more minute of the arteries, and a localized anaemia of the spinal cord 
was thus produced. The result was, that the posterior extremities of 
the animal were almost immediately paralyzed. 

Feltz 4 injected finely-powdered charcoal into the right crural artery 

1 "Le9ons sur l'appareil vaso-moteur," etc., Paris, 1875, tome ii., p. 48, et seq. 

2 " Lectures on the Diagnosis and Treatment of the Principal Forms of Paralysis of 
the Lower Extremities," Philadelphia, 1861, p. 24. 

3 " Comptes rendus de TAcademie des Sciences," 1847, p. 905. 

4 " Traite clinique et experimental des embolies capillaires," Paris, 1870, p. 186. 



SPINAL ANEMIA. , 403 

of a dog, so that the injection passed into the inferior part of the ab- 
dominal aorta. The animal was at once paralyzed in the right posterior 
extremity, and shortly afterward, in the corresponding limb of the 
opposite side. After death, particles of the powder were found in the 
spinal arteries. 

Vulpian 1 has several times repeated these experiments, using the 
powder of lycopodium, and has invariably found the animals become 
almost instantly paraplegic. 

Nevertheless, he is not sure that the paralyses, called reflex, are the 
result of spinal anaemia; on the contrary, he doubts if, in reality, there 
are any such affections. He is disposed to think that they are to be 
classed in several categories ; one embracing cases in which there is a 
definite lesion of the cord ; another, those cases which occur in hyster- 
ical, hypochondriacal, and epileptic persons, from irritations existing in 
distant parts of the body, and which he calls paralyses of peripheral 
origin ; and a third, comprehending all instances which cannot be in- 
cluded in either of these classes, and especially embracing the cases due 
to the action of cold on the surface of the body. 

M. Vulpian's chief objection to the theory of spinal anaemia is that, 
when the arteries are occluded by artificial emboli, softening of the cord 
takes place. This is doubtless true in the majority of cases, but cer- 
tainly not in all, for in the dog, which was the subject of Feltz's experi- 
ment, life was prolonged for two days, and it is expressly stated that 
the cord was not softened. Moreover, in the anaemia produced by 
peripheral irritations the vessels are not entirely closed. Their calibre 
is simply diminished ; some blood reaches the cord, but this is not 
sufficient for the full performance of its functions. If softening were 
the invariable result of a lessened supply of blood to an organ, we 
should meet with it constantly in cases of general cerebral anaemia from 
any one of the many causes capable of producing that condition. 

Now, I have repeatedly performed Flourens's experiment, both with 
powdered lycopodium and charcoal, and have never failed to obtain 
paralysis of the posterior extremities. It is true the loss of power was 
permanent, remaining in each case during the life of the animal, but 
such a result is, of course, to be expected, for it is impossible to get rid 
of the substances occluding the vessels. In the anaemia produced by 
reflex irritation or spinal exhaustion, the possibility of removing the 
cause, overcoming the vaso-motor spasm, or improving the nutrition of 
the cord, places the condition entirely in a different line from that due 
to mechanical occlusion of the vessels, except as regards the one point 
of anaemia, and even here the difference is great, for in the former the 
supply of blood is merely lessened, while in the latter it is cut off 
altogether. 

In practice we often find that the anaemia is not restricted to either 
1 Op. cit, p. 53. 



404 DISEASES OF THE SPINAL CORD. 

set of columns, and that the symptoms are accordingly those of motor 
paralysis, aberrations of sensibility, and functional disturbances in va- 
rious organs, such as we have just considered as being caused by 
anaemia of the posterior columns. 

Treatment. — The treatment is similar in general features to that ap- 
plicable to anaemia of the posterior columns already considered, though 
there is not the same benefit to be derived from counter-irritation. The 
indications, therefore, are to remove the cause, to improve the general 
tone of the system, and to increase the amount of blood in the spinal 
vessels. 

So far as the first indication is concerned, it very often happens that 
its fulfillment is sufficient for the entire removal of the anaemia, and the 
disappearance of the consequent paralysis. This is especially the case 
as regards those instances which are due to peripheral irritations of va- 
rious kinds. Within the last few days a young lady, aged twelve, was 
brought to me by her mother to be treated for paraplegia, which had 
developed very suddenly. There was no evidence of serious organic 
difficulty, and no apparent cause of peripheral irritation. Her symp- 
toms, however, all pointed to anaemia of the antero-lateral columns, and, 
on the principle of exclusion, I thought it probable there might be 
worms in the alimentary canal. I therefore administered several doses 
of santonine, followed by castor-oil. A number of lumbrici were dis- 
charged, and the paralysis disappeared in the night as suddenly as it 
had arisen. 

In another case, a gentleman was rendered paraplegic soon after 
contracting a catarrhal inflammation of the bladder. The bladder affec- 
tion was disregarded by his physician, and energetic means were used 
against the paralysis, but without effect. I suggested the expediency 
of suspending the administration of the strychnia and the application 
of counter-irritants to the spine, and directing attention to the cure of 
the disorder of the bladder. This was done, and, at the same rate as 
the inflammation yielded to the treatment, the paraplegia disappeared. 

The general tone of the system is to be improved by such measures 
as were recommended for the accomplishment of the same end in anae- 
mia of the posterior columns. 

For fulfilling the third indication, strychnia and phosphorus are pref- 
erable to any other internal remedies. I usually prescribe them together 
in doses of the tenth of a grain of the phosphide of zinc, with from a 
third to a half a grain of the extract of nux- vomica in pill, to be taken 
three times a day. Lately, however, I have pursued the practice of giv- 
ing the strychnia in gradually-increasing doses till there is evidence of 
its characteristic physiological effects being produced. Two grains of 
the sulphate of strychnia are to be dissolved in an ounce of water, and 
ten minims, containing one twenty-fourth of a grain of strychnia, given 
three times a day ; the next day eleven minims are administered for 



SPINAL ANEMIA. 405 

each dose, the next twelve, and so on till, as often happens, the paraly- 
sis yields, or till the reflex excitability of the legs is increased, or stiff- 
ness of their muscles or those of the nucha is induced. In either of 
these latter events the administration must be stopped for a day, and 
then the original dose of ten minims be given and increased as before. 
There is, according to my experience, no medication so effectual in all 
those forms of paralysis called reflex, inhibitory, functional, etc., and 
which, in my opinion, result from anaemia of the antero-lateral columns 
of the cord, as this with strychnia. It requires care and prudence, and, 
if these qualities be exercised, is perfectly safe. It very generally hap- 
pens that, before the patient reaches thirty minims (one-eighth of a 
grain) for a dose, the paralysis begins to yield. In one case, however, 
due to exposure to severe cold, I was obliged to carry the dose to sixty 
minims — equal to one-fourth of a grain of strychnia — before the excita- 
bility of the cord was increased, or any signs of the paralysis yielding 
were observed. The patient recovered after taking three-quarters of a 
grain of strychnia daily for over two weeks. 

In a very remarkable case recently under my care, sent to me by 
Dr. Brooks, of Cleveland, the paralysis following diphtheria affected 
both arms and both legs, and was evidently increasing daily in inten- 
sity. At last, the patient could scarcely move a muscle of either ex- 
tremity, and was, of course, unable to walk. Strychnia was adminis- 
tered according to the manner .above described, and also by hypodermic 
injections. Amendment was slow but steady, and I sent him home, 
where, under Dr. Brooks's care, who boldly carried out the treatment^ 
he entirely recovered. At no time, while under my observation, was 
there any evidence of strychnization, although large doses of the 
remedy, amounting at one time to a grain a day, were given. The irri- 
tability of the cord appeared to be entirely abolished. Neither the 
bladder nor rectum was paralyzed, and cutaneous sensibility was scarce- 
ly impaired. 

The only local application which is decidedly beneficial in anaemia 
of the antero-lateral columns is the constant galvanic current, which 
should be used in the manner recommended for anaemia of the poste- 
rior columns. 

As regards the paralyzed muscles, the induced or faradaic current is 
useful in keeping them exercised, and thus preserving their nutrition. 
Friction and kneading exercise a like effect. 

In those cases of spinal anaemia due to obstruction of the aorta, or 
occlusion of spinal vessels by emboli, no specific treatment is of any 
avail. 



406 DISEASES OF THE SPINAL CORD. 

CHAPTER III. 

SPINAL HEMORRHAGE-SPINAL MENINGEAL HEMORRHAGE. 

These two conditions having a common cause, being often associ- 
ated, and having a general resemblance to each other, may properly be 
considered together. 

Symptoms. — A haemorrhage into the substance of the spinal cord is 
characterized by pain at the seat of the lesion, and by derangements 
of sensibility and of the power of motion in all those parts of the body 
below. These consist of anaesthesia and loss of motility, but occasion- 
ally there are hyperesthesia and spasms. In the majority of cases the 
bladder and its sphincter and the sphincter ani are also paralyzed. Ob- 
stinate priapism is an occasional symptom. Reflex excitability and 
electro-muscular contractility are soon impaired or altogether lost. 

An elevation of temperature is said * to take place in the paralyzed 
parts, and the formation of sloughs on the sacrum and other parts ex- 
posed to pressure is a frequent occurrence. In a case under my own 
observation, a man fell from a scaffold and struck the small of his 
back against a projecting beam. He was taken up paraplegic, and 
within six hours three large sloughs — one over the sacrum and one over 
each hip — made their appearance. Sensibility was entirely abolished in 
the paralyzed limbs. The bladder and rectum were completely para- 
lyzed, and death ensued on the fifth day. Post-mortem examination 
discovered a clot in the substance of the cord, extending from the tenth 
dorsal to the fifth lumbar vertebra, and involving both the white and 
the gray substance. There was neither fracture nor luxation. 

Haemorrhage into the substance of the cord may be either rapidly 
or slowly developed. In the former case it generally terminates fatally 
in a few days or even hours ; in the latter, life may be prolonged for 
several months, or may be preserved, with more or less paralysis of 
motion or sensibility, or, as is generally the case, of both in the parts 
below the seat of the lesion. 

If the seat of the haemorrhage be high up 'in the neck, death is 
almost instantaneous from the paralysis of the phrenic nerve. 

When the lesion is meningeal, the symptoms are not generally so 
rapidly developed as when it is situated in the substance of the cord. 
The pain is greater, and there is a more decided tendency to spasmodic 
jerkings in the limbs receiving their nerves from the part of the cord 
below the extravasation. Occasionally the convulsive movements are 
general, and, according to Hayem, are more marked in the paralyzed 
than in the non-paralyzed limbs. Hyperaesthesia may alternate with 
anaesthesia, or this latter may alone be present. 

1 Hayem, "Des hemorrhagies intra-rachidiennes," Paris, 18*72, p. 186. 



SPINAL HEMORRHAGE. 407 

The extent of motor paralysis is very variable, both as regards in- 
tensity and diffusion. Sometimes all the muscles below the seat of the 
lesion are more or less paralyzed ; at others, some muscles altogether 
escape. I have a patient under treatment who has, in consequence of 
a spinal haemorrhage, probably meningeal, lost sensation in a small 
region of skin over the glutei muscles, and sensation and motion in all 
the tissues below both knees. Sensation and motion are intact in all 
other parts of the lower extremities. The bladder is unaffected, but 
there is very obstinate constipation. 

Reflex excitability is often exaggerated, and the electro-muscular 
contractility increased in the early stage ; but, if the patient survives 
the immediate effects of the lesion, both these faculties become im- 
paired, or abolished altogether. If the patient survives the injury, he 
remains paralyzed to a degree corresponding to the extent of the 
injury to the spinal cord. In severe cases there will be complete 
paraplegia with anaesthesia from the lesion downward, all reflex ex- 
citability will be abolished, and atrophy of the paralyzed muscles soon 
begins, and progresses, until all or nearly all of the muscular tissue 
has disappeared. Meningeal hasmorrhage taking place above the third 
cervical vertebra may be speedily fatal, from the interruption to res- 
piration due to paralysis of the phrenic nerve. 

Causes. — Spinal haemorrhage, either in the substance of the cord or 
of the membranes, is generally the result of injury. Thus it may be 
caused by blows on the vertebral column, by falls, or by gunshot, or 
by wounds with penetrating instruments. It may also be produced by 
tetanus and by the rupture of aneurisms, but is in either of these cases 
meningeal. Excessive fatigue, the suppression of the menstrual flow, 
undue venereal indulgence, alcoholism, yellow fever, typhoid fever, 
disease of the vertebrae, and the toxic influence of strychnia, have also 
been alleged as causes. In many cases not traumatic the immediate 
cause is not known. The male sex appears to be much more liable 
than the female. Of nineteen cases of haemorrhage into the substance 
of the cord analyzed by Gintrac, 1 fifteen were in males. 

Diagnosis. — The diagnosis must mainly be determined by the his- 
tory of the case, and by the facts that the symptoms come on suddenly 
and advance rapidly. Often there are great difficulties experienced in 
arriving at a satisfactory opinion relative to the diagnosis, and I 
quote the following case not only because of its interest, but because 
it illustrates the scientific acumen of a distinguished member of 
the medical profession. Under the designation of "case of spinal 
apoplexy," Dr. Robert Jackson 2 says : 

1 " Traite theorique et pratique des maladies de l'appareil nerveux," Paris, 1869, 
tome ii., p. 423. 

2 Quoted in Quarterly Journal of Psychological Medicine and Medical Jurisprudence, 
New York, 1869, vol. iii., p. 810, from the Lancet. 



408 DISEASES OF THE SPINAL CORD. 

" On Sunday, May 2, 1869, Miss F. L., a bright, merry, healthy, 
and well-developed young lady, aged fourteen, arose as usual, but while 
dressing said ' her fingers felt weak.' She, however, went to church, 
both morning and evening, and seemed quite well. 

" On Monday, she again got up as usual, but complained of the same 
* weak feeling ' in her hands. Otherwise, she felt very well; participated 
in the usual studies of the day; and in the evening had a warm bath, 
enjoyed it, and got into it ' with the use of all her limbs.' 

"On Tuesday she was much the same; ate a good breakfast, feed- 
ing herself, etc. During the forenoon, however, the weak feeling con- 
siderably increased, and I was sent for. I found her lying on her back 
in bed, quite merry, laughing, free from all pain, and rather amused, 
than otherwise, at her condition. She was, however, unable to shake 
hands with me, or to move her arms, except at the wrists ; and failed 
altogether to pick up a pin placed on a book before her. 

"On Wednesday, there was no material alteration. I observed, 
however, that the intercostal muscles were not acting quite freely ; she 
seemed, too, to lie heavier in her bed, and she evidently was now unable 
to turn herself round. There was also a moist crepitant rdle over all 
the chest, with a little cough. The secretions continued free, the pulse 
regular; and she ate, being fed, a good dinner of roast-beef. 

" On Thursday, Sir William Jenner kindly saw her with me. Her 
general condition was not greatly altered ; every sensation perfect ; no 
anaesthesia ; and she displayed her usual quick perception and intelli- 
gence. A careful examination, however, at this time, clearly demon- 
strated a great and decided loss of power in all the voluntary muscles 
of respiration, and in those muscles of the arms, back, and chest, sup- 
plied by the branches of the cervical nerves. The diaphragm, too, was 
becoming fixed, and there was slight lividity about the cheeks, with a 
fall of the natural temperature. 

" From these symptoms, it became evident that there was some 
serious spinal lesion, implicating probably, and more particularly, the 
anterior branches of the cervical nerves, and the origin of the phrenics. 
Sir William Jenner diagnosed, and, as will be seen, with perfect accu- 
racy, a clot in the cervical portion of the spinal cord, and he prognosed, 
notwithstanding the bright life and still merry laugh, a speedy and 
fatal result. This took place thirty hours afterward, without pain, 
without loss of consciousness or sensation, but only as the cessation of 
the power of respiration became more and more determined, with a 
desire to be raised ' higher and higher.' 

" In this interesting case a post-mortem examination was kindly 
allowed, and made forty hours after death. There was slight opacity 
of the dura mater in several places. Brain congested and soft. A soft- 
ened spot and ill-defined clot in the cerebellum. The whole cervical 
portion of the spine, but particularly anteriorly, and to the left side, 



SPINAL HEMORRHAGE. , 409 

was imbedded in an oblong clot of dark venous blood outside the mem- 
branes. The whole length of the cervical portion of the canal and the 
dura mater were deeply tinged by the color of the clot. The cervical 
nerves all passed through this effused blood, the inter-vertebral canals 
on both sides being filled with it. So soon as the seventh cervical ver- 
tebra was reached, the clot ceased, and the cord and canal assumed 
their normal condition and color. There was also a good deal of semi- 
clotted blood about the pons and the nerves arising from it. 

" It is certainly a matter of much difficulty to account satisfactorily 
for this great effusion of venous blood in a subject so young and so 
apparently healthy and robust. No outward cause could be assigned; 
there had been no blow or injury; no illness ; no interrupted function ; 
but, living with kind and affectionate relations, she enjoyed every com- 
fort and happiness. It might have been assumed that so great a lesion, 
situated in so important and vital a position, would have given rise to 
more decided and grave symptoms from the beginning. The only 
probable explanation is, that the effusion took place very gradually, 
had room to extend itself, and coagulated slowly, and imperfectly. 
Until the paralysis of the diaphragm showing dangerous interference 
with the functions of the phrenic nerves, nearly every symptom might 
have been attributed to one or other of those obscure forms of hysteria 
so frequently met with in practice." 

Prognosis. — Death is the almost invariable result. I have, however, 
known two instances of recovery. In one of these the patient, a boy 
of about fifteen, was thrown from his horse. Paralysis supervened im- 
mediately, and there was a severe pain at about the eleventh dorsal 
vertebra. The bladder was also paralyzed. For several weeks his life 
was despaired of, but he eventually recovered with the paraplegia re- 
maining, and the necessity of drawing off the urine with a catheter. I 
saw him five years after the injury. He was still paraplegic, and the 
bladder was still paralyzed. Careful examination failed to show any 
displacement or fracture of the vertebra, and I therefore felt warranted 
in concluding that there had been a spinal haemorrhage, probably men- 
ingeal. The other case has been already cited. In this, the patient 
fell through a hatchway a distance of thirty feet, and struck on his 
back. Paralysis was almost immediate. He came under my care fif- 
teen years after the event, and I diagnosticated a meningeal spinal 
haemorrhage from the fact that there had been violent jerkings of 
the limbs and intense lumbar pain. There were no signs of fracture 
or displacement. But in these, as in the following case, which I 
select from others similar, cited by Mr. Le Gros Clark, 1 there is, of 
course, room for doubt relative to the correctness of the diagnosis. 

1 " Lectures on the Principles of Surgical Diagnosis, especially in Relation to Shock 
and Visceral Lesions, delivered before the Royal College of Surgeons of England," Lon- 
don, 1870, p. 146. 



410 DISEASES OF THE SPINAL CORD. 

The patient, a man thirty-six years of age, weighing 11^ stones, 
gave the following account of himself : He was tripped up in the road, 
and fell heavily on his left hip, and then turned over on his back. On 
trying to rise, he failed, not having any power of movement in either 
lower extremity. He was at once, brought to the hospital. On admit- 
tance, he complained of pain in the lumbar region, and there was slight 
tenderness on pressing the spinous ridge of this part ; but careful 
examination failed to detect any irregularity, or any sign of mechanical 
injury of the vertebral column. There was entire loss of power in his 
lower limbs — he could not even move a toe ; sensation was impaired ; 
he said his limbs were numbed. There was slight priapism, and he was 
unable to micturate. His pulse was 60 ; but there were no signs of 
well-marked collapse. On the third day he was able to move his toes 
a little. On the ninth day, sensation was perfect ; but he had made 
very little progress in regaining muscular power. Nearly three weeks 
elapsed before he was able to dispense with the catheter ; and, at the 
expiration of five weeks, he was still almost as helpless in moving any 
part of his lower extremities. He remained in the hospital for four 
months, his health being tolerably good throughout. He was then able 
to get about very fairly, but with a shuffling, unsteady gait." 

Mr. Clark then remarks : 

" The causative accident in this case was slight, too trivial to pro- 
duce fracture, and the symptoms were not those of sprain. There were 
no physical signs of displacement; yet, the paraplegia was marked; but 
not including corresponding loss of sensation, which would have been 
present if a displaced vertebra had pressed upon the cord. The slow 
recovery was a gradual confirmation of the diagnosis, that fracture with 
displacement was not the injury to which the symptoms were due. 

" But, I must admit, I cannot dismiss from my mind that in these 
and similar protracted cases, there is something more than simple con- 
cussion needed to account for the duration of the symptoms; probably 
extravasation of blood into the theca or canal which is slowly absorbed. 
I do not think that the unequal effects produced on the several columns 
of motion and sensation forbid this supposition, for this effect is by no 
means uncommon, being usually in favor of sensation, where the in- 
equality is noticed, and indicating that the anterior half of the cord and 
part of the lateral columns are the parts implicated. A child three and 
a half years old was admitted under my care, who had been run over by 
a heavy sand-cart, sixteen days previously ; the wheel passed over the 
loins. There was nothing particular noticed at the time, except her in- 
ability to walk as well as usual. This inability increased, and, when seen 
by me, she could scarcely manage, when held up, to shuffle her feet along. 
She complained of no pain, had no difficulty in passing her water, and 
the sensibility of the legs seemed to be in no degree impaired. On 
careful examination, there was nothing abnormal to be observed in any 



SPINAL HEMORRHAGE. 41 1 

part of the spine. The treatment consisted in rest, and friction of the 
back with liniment of ammonia. She remained in the hospital five 
weeks, and, then left quite well. 

" A remarkable case was mentioned to me by the late Dr. Dyer, 
who acted for the Brighton Railway Company. A man was injured in 
a collision in the tunnel four or five miles from Brighton. He walked 
this distance with some difficulty into the town, and within twenty -four 
hours became entirely paraplegic. He recovered slowly, and after the 
lapse of two years was able to walk as well as before the accident. 
One spot on the back was always tender, and continues so still at times. 
The analogy between this case and a similar but fatal injury which I 
have already mentioned, seems to point to haemorrhage as the probable 
cause of the protracted symptoms." 

Of like character appears to have been the following case, which I 
cite from Dr. John Ashurst's 1 admirable monograph: " A male child 
of two years was admitted to the Pennsylvania Hospital on November 
13, 1861, having a short time previously received a severe blow upon 
the back. There were no external marks of injury, but the lower limbs 
were paralyzed, doubling up upon themselves when an effort was made 
to place the child in an erect position. He was discharged cured, after 
two months, his treatment having consisted in little else than rest in a 
recumbent posture." 

Several of the cases given by Mr. Erichsen, 2 in his excellent little 
work, appear to present many of the features of spinal haemorrhage. 
It is, therefore, quite probable, making all due allowance for uncer- 
tainty in the diagnosis, that the affection in question, especially when 
resulting from traumatism, is not an entirely hopeless condition. 

Morbid Anatomy and Pathology. — The blood in haemorrhage of 

the spinal cord is effused either into the substance of the cord or into 
its membranes. It may, therefore, be situated in the nervous tissue ; 
in the subarachnoidal space; in the intra-arachnoidal space ; or in the 
space between the dura mater and the walls of the vertebral canal. 
In the first-named situation the gray matter is invariably — so far as 
our knowledge extends — the place of origination, unless we except 
certain possible traumatic cases. The clot shows a greater tendency to 
extend in the course of the long axis of the cord then laterally, and 
may vary in length from half an inch, or less, to three or four inches, 
or may involve the whole of the central portion of the cord. 3 The 
white substance rarely gives way to the interior pressure, but remains 
as a distinct boundary to the further extension of the clot in a lateral 

1 " Injuries of the Spine, with an Analysis of nearly Four Hundred Oases," Phila- 
delphia, 186*7, p. 8. 

8 " On Concussion of the Spine, Nervous Shock, and other Obscure Injuries of the 
Nervous System in their Clinical and Medico-Legal Aspects," London, 1875. 

8 Hayem, op. cit., p. 152; Cruveilhier, " Anatomie pathologique," book ill., plate vt 



412 DISEASES OF THE SPINAL CORD. 

direction. Occasionally, however, this tissue gives way, and the clot 
appears as a tumor under the meninges. This was the case in a pa- 
tient whose clinical history is related by Cruveilhier, and which is fur- 
ther remarkable by the fact that five years before the attack which 
terminated in death, the patient had experienced suddenly a severe 
pain in the neck, and paralysis of the left arm and leg. He recov- 
ered in three months. The post-mortem examination revealed the ex- 
istence of an old apoplectic cyst in addition to the extravasation of 
the final haemorrhage, which latter extended throughout the whole 
length of the cord, and had in several places broken through the 
white substance, being only restrained by the spinal membranes. 

The clot may either present the general appearance of blood, and 
may, in fact, consist almost entirely of this substance, or it may, as is 
the case in cerebral haemorrhage, consist of blood and the cttbris of the 
nervous tissue. The changes which ensue in the clot and in the limit- 
ing tissue are similar to those which take place in the brain under like 
circumstances. 

In spinal meningeal haemorrhage the blood is, as above stated, ex- 
tra vasated between the bones and the dura mater — extra-meningeal 

o 

haemorrhage ; between the layers of the arachnoid — intra-arachnoidal 
haemorrhage ; or between the arachnoid and the pia mater — subarach- 
noidal haemorrhage : 

The extra-meningeal hoemorrhages are those which are especially 
apt to occur as the result of traumatic cause. The extravasation is 
generally extensive, and may occupy the entire extra-meningeal space 
— though, generally, it is circumscribed within much smaller limits. 
The cervical region is most apt to be its seat, and the dorsal next. 

In ijitra-arachnoidal spinal haemorrhage the blood is not effused in 
such large quantity as in the variety just described, and, moreover, 
generally has its source in a cerebral haemorrhage — rarely being autoc- 
thonous. It is collected in a sac, and may exercise more or less com- 
pression on the cord according to the amount extravasated. 

Sub-arachnoidal haemorrhage is the rarest of all the forms. The 
blood is here extravasated into the meshes of the pia mater, and may 
compress the cord. 

Of fifty-eight cases of spinal-meningeal haemorrhage, cited by 
Hayem, thirty-eight were instances in which the blood was extravasated 
between the bones and the dura mater ; eleven were intra-arachnoidal ; 
and eight were sub-arachnoidal. 

The symptoms which follow spinal haemorrhage are the results of 
excitation and compression — the hyperaesthesia and the spasms being 
due to the former, and the anaesthesia and motor paralysis to the latter. 

Treatment. — There is nothing to do in cases of spinal haemorrhage 
but to maintain the patient in as quiet a condition as possible, and to 
keep ice constantly applied to the vertebral column. If there is time, 



SPINAL MENINGITIS. 413 

ergot might be administered with advantage. In two cases which I 
have had the opportunity of observing from the first, both caused by 
falls from the loft of a stable, death took place within six hours ; the 
symptoms gradually becoming more profound and advancing upward. 
After death, the haemorrhage was found to occupy the whole length of 
the spinal canal, and was seated between the bones and the dura mater. 
Of course, in cases like these, no therapeutical means can avail, and, 
even in slighter cases, treatment is of little if any service. We may, 
however, by perfect rest, ice to the spine, leeches to the anus, and the 
administration of ergot, sometimes prevent haemorrhage in cases of in- 
juries of the cord which otherwise might be followed by extravasation. 

In cases not due to traumatism, and especially in those which are 
slow in their progress, more is to be expected from the use of remedial 
measures. Ergot should be energetically administered in large doses, 
two or three drachms every four hours, or, what is perhaps preferable, 
ergotin should be given to the extent of five grains hypodermically, as 
often. The other measures above mentioned should also be employed; 
with the view of causing absorption of the effused blood, the actual 
cautery applied to the spine in the vicinity of the lesion has been 
recommended. It should not be used till it is evident, from the non- 
progressive character of the symptoms, that the extravasation is no 
longer going on. 

Strychnia is altogether inadmissible at any time in the course of 
the disease. 



CHAPTER IV. 

SPINAL MENINGITIS. 



Inflammation of the membranes of the spinal cord may be eithsr 
acute or chronic. 

ACUTE SPINAL MENINGITIS. 

Acute inflammation may be seated either in the dura mater, the 
arachnoid, or the pia mater of the cord, or may simultaneously attack 
all three membranes. 

Symptoms. — The symptoms indicating inflammation of the dura ma- 
ter are not very decided, and beyond the occurrence of pain may not 
be observed at all. When combined with inflammation of the arach- 
noid and pia mater, the phenomena are more pronounced. 

Acute inflammation of the arachnoid does not of itself give rise to 
characteristic symptoms, and it is rarely the case that it exists sepa- 
rately. 



414 DISEASES OF THE SPINAL CORD. 

Acute inflammation of the pia mater can, however, be recognized 
without difficulty. It begins with a chill, as do others of the phleg- 
masia?, and this is soon followed by febrile excitement. At the same 
time there is intense pain in the back, which is aggravated by every 
movement of the patient, but not by pressure on the part of the spine 
over the diseased portion of the membrane. Those nerves which have 
their origins from the affected region are the seat of severe pain, which 
is transmitted through their trunks and branches to distant parts of 
the body. Spasms of the muscles of the back are commonly present. 
These are tonic in character, and may be so severe as to bend the 
body backward, producing an appearance like the opisthotonos of 
tetanus. At the same time the limbs below the seat of the lesion are 
strongly contracted. I have witnessed cases in which the knees were 
drawn up to the chin, and the heels to the buttocks. 

At the same time there is impairment of motor power in all those 
parts of the body supplied by nerves coming from the cord below the 
diseased region, and in some cases voluntary control over the muscles 
is entirely lost. 

The skin is generally acutely hyperaBsthetic, and pressure on the 
muscles below the lesion usually elicits pain. 

While the affection is confined to the membranes of the lower por- 
tion of the cord, a fatal result may be deferred for some time, and the 
disease may become chronic ; but, if it extends upward so as to in* 
volve the region from which the phrenic nerves arise, death very soon 
takes place by asphyxia. 

So long as the spinal cord continues free from the disease, the reflex 
excitability and electro-muscular contractility remain unimpaired. 

The bladder is not often involved, and the bowels may be obstinately 
constipated, or the fecal matters may be passed involuntarily. 

CHRONIC SPINAL MENINGITIS. 

This may arise in consequence of an acute attack, or it may be de- 
veloped spontaneously. As in the acute form of the affection, pain 
constitutes a prominent feature, and is situated both in the spinal region 
and in other parts of the body. Spasms and contractions of the lower 
extremities, and spasms of the muscles of the back, are likewise promi- 
nent symptoms. 

The pain in the spine is not increased by steady pressure over the 
vertebras, but it is greatly aggravated by every movement of the body; 
for by such motion the nerves are compressed as they leave the spinal 
canal, and, as they are already in a condition of erethism, pressure can 
not be borne. 

The abnormalities of sensation are usually in the way of hyperes- 
thesia, which may sometimes be very acute. 



SPINAL MENINGITIS. 415 

The paralysis advances gradually, and rarely, at first, is very intense 
in any group of muscles. It is likewise subject to great variations in 
the degree of severity. Sometimes the patient finds that he walks 
tolerably well one day, while the next he can scarcely move a limb. 
These differences depend on the amount of fluid effused, which is sub- 
ject to changes from day to day. 

The bladder is sometimes paralyzed, the sphincter may be similarly 
affected, or this latter may be subject to repeated attacks of spasm, 
by which the evacuation of the urine is prevented. 

The bowels, as in the acute form of the disease, may be either con- 
stipated, or the sphincter ani may be so paralyzed as to allow of the 
involuntary passage of the fecal matters. 

Reflex excitability is rarely lessened, and is often considerably in- 
creased. In the case of a gentleman from Ohio who was recently un- 
der my charge for chronic spinal meningitis, the slightest touch on the 
sole of the foot was sufficient to cause the limb to be violently drawn 
up; and, in the case of a lady from New Orleans similarly affected, the 
contact of the bedclothes produced a like effect. 

In several cases I have observed that any mental agitation, or even 
the attention directed to the affected limbs, was sufficient to cause vio- 
lent spasmodic contractions. 

Electro-muscular contractility is not generally impaired. 

The symptoms are usually aggravated by the recumbent posture. 

Bed-sores are a frequent accompaniment of chronic spinal menin- 
gitis. 

Causes. — The most common cause of spinal meningitis, either acute 
or chronic, is exposure to cold and moisture. Several cases have come 
under my charge which clearly resulted from lying on the cold and 
damp earth, and from going to sleep in this situation. In one case 
which occurred in a railway conductor, the train of which he had charge 
was obstructed in its passage by a heavy drift of snow. While work- 
men were cutting a way through it, he lay down on a pile of snow, and, 
being greatly exhausted, quickly fell asleep. Soon after being awakened 
he had a slight chill and a mild fever, and the following day experienced 
severe pain in the back. This was soon followed by the other symp- 
toms of spinal meningitis, not very intense in character, but persistent, 
for the affection passed into the chronic form. Two cases have come 
under my notice in which the disease was caused by the back being 
exposed to a strong and cold wind. 

On account of this influence of cold in producing spinal meningitis, 
the disease is far more common in winter than in summer. Of the 
cases that I have treated wholly or in part during the last twelve 
years, by far the greater number occurred in the months from Novem- 
ber to March, inclusive. 

Exposure to the direct rays of the sun is said to induce spinal 



416 DISEASES OF THE SPINAL CORD. 

meningitis, but I have never witnessed a case in which this cause could 
reasonably be inferred. I may make the same remark in regard to 
the effects of strong muscular exercise. 

It is, however, sometimes a consequence of wounds and injuries. 
Seven of the cases under my charge were due to traumatic causes. 

Rheumatism is likewise an occasional, and syphilis quite a com- 
mon cause. 

Diagnosis. — The diagnostic phenomena of spinal meningitis, either 
of the acute or chronic form, are the pain in the back, increased on any 
movement of the spinal column ; the pains in the course of the nerves 
having their origin from the diseased region ; the tonic spasms of the 
muscles of the back, and of other parts of the body ; the exaltation of 
reflex excitability and hyperesthesia ; and the variations which take 
place in the extent and intensity of the paralysis. 

Prognosis. — The course of spinal meningitis is generally progressively 
onward to a fatal termination — the patient dying either by the gradual 
extension of the disease upward so as to involve more important nerves 
in the lesion, by the development of some intercurrent affection, or by 
exhaustion. I have, however, seen five cases in which the disease was 
arrested, three of which will be more specifically referred to under the 
head of treatment. And Ollivier, 1 Brown-Sequard, 2 and Jaccoud, 3 admit 
the possibility of cure. When of syphilitic origin the prognosis is 
much more favorable. 

Morbid Anatomy and Pathology. — The lesions found after death 

from spinal meningitis may be confined to any one of the membranes, 
but more generally are restricted to the pia mater and the sub-arach- 
noid space. They consist in thickening of the membrane, spots of 
opacity, turgidity of the vessels, and the effusion of a large quantity of 
spinal fluid. This fluid is occasionally clear, but is more frequently full 
of flocculent matter, or is tinged with blood. 

The alterations found in the arachnoid are of similar character, with 
the addition that there are numerous hard cartilaginous plates scattered 
through the diseased part of the membrane, which vary in size from 
that of a grain of wheat to a mustard-seed. 

The dura mater, when it has been the seat of inflammation, becomes 
thickened and adherent to the bone. Occasionally it is perforated by 
the supervention of gangrene, and the pus collected between it and 
the vertebrae escapes into the space between the dura mater and arach- 
noid, and excites general meningitis. 

Ollivier reports 4 the case of a child three or four years old, whc 
entered the hospital February 2, 1823. There were great difficulty of 

1 " Traite des maladies de la moelle epiniere," etc., Paris, 1827, tome ii., p. 295. 

2 Op. cit. t p. 302. s Op. c&, p. 82. 

4 " Traite des maladies de la moelle epiniere," troisieme Edition, Paris, 1837, tome ii., 
p. 272. 



SPINAL MENINGITIS. 417 

deglutition, a remarkable fixedness of the eyes, tetanic convulsions — 
trismus, opisthotonos — coma, and permanent contractions of the lower 
extremities. Death ensued on the twelfth day after admission. On 
post-mortem examination the membranes of the brain were found to be 
thickened and opaque, the substance of the organ was injected, and the 
ventricles contained an excessive amount of fluid. In the spine at the 
middle of the dorsal region, there was a very thick reddish infiltration 
in the cellular tissue, between the dura mater and the bony canal. On 
incising the membranes, it was seen that their cavity was filled with 
serum; the vessels of the pia mater were intensely congested. The sub- 
stance of the cord was slightly injected. 

Michaud, 1 under the name of external pachymeningitis, has de- 
scribed an inflammation of the dura mater, which he has found to be 
the affection of the membranes generally produced by Pott's disease. 
It consists in a thickening of the dura mater by deposits of yellow- 
colored granulations, which by their confluence form plates which are 
attached by their inferior surface to the membrane. Under them the 
dura mater appears to be healthy. At first they are only developed in 
the vicinity of the osseous lesion, but they have a tendency to extend, 
and may involve the whole length of the membrane. The existence of 
these formations was first noticed by E. Wagner a in a case of Pott's 
disease, of which he made the post-mortem examination. This inflam* 
mation of the dura mater may result in little abscesses, scattered 
through its lamina, or larger collections of pus may be formed in the 
substance of the new formation. 

The symptoms, as Leyden 3 and Rosenthal 4 admit, are simply those 
of the other forms of spinal meningitis. 

The internal surface of the dura mater may also be the seat of 
morbid processes. Two of these modes have been differentiated. One 
constitutes the cervical hypertrophic pachymeningitis of Charcot ; 6 
the other is the internal hemorrhagic pachymeningitis of A. Meyer 6 
and others. As described by Charcot, cervical hypertrophic pachy- 
meningitis consists in an alteration of the meninges, especially the dura 
mater. The seat of the lesion is variable, but the cervical enlargement 
appears to be the place generally affected. The alteration of the dura 
mater is the primary fact; the other membranes, the cord itself, and the 
nerves coming from it, subsequently become involved. Formerly, the 
disease was mistaken, as by Laennec, Andral, and Hutin, for a primary 

1 " Sur la meningite et la myelite dans le mal vertebral," Paris, 1871, p. 9. 

2 " Pathologisches, anatomisches und klinisches Beitrage zur Kentniss der Gefass- 
aerven," Archiv der Heilkunde, Heft 4, 1870, S. 321. 

9 "Klinik der Eiickenmarks-krankheiten," Berlin, 1874, Erster Band, S. 388. 

4 " Klinik der Nerven-krankheiten," Stuttgart, 1875, S. 280. 

5 "Memoires de la Societe de Biologie," 1871, p. 35, and " Le9ons sur les maladies 
du systeme nerveux," Paris, 1874, p. 246. 

* " De Pachymeningitide cerebro-spinali interna," Bonnae, 1861. 

28 



418 



DISEASES OF TIIE SPINAL CORD. 



affection of the spinal cord, and was described by them as hypertro- 
phy of this organ ; and the error is in a measure sustained by the fact 
that, in cases of the disease in which the vertebral canal is opened, 
the spinal cord and its membranes are seen to completely fill the canal. 

But, upon making a transverse section of the cord, it is at once 
perceived that the swelling is due to the thickening of the envelopes, 
and that the marrow, so far from being enlarged, is in reality com- 
pressed and flattened from before backward. 

In the accompanying engraving (Fig. 31), taken from Joffroy's 1 



Fig. 31. 




memoir, the appearances are well exhibited (a, the hypertrophied dura 
mater; b, nerve-roots traversing the thickened membranes; c, the pia 
mater confounded with the dura mater ; d, lesions of chronic myelitis ; 
e, section of canals newly formed in the gray substance). 

As will readily be perceived, the pia mater is involved in the morbid 
process, but not to the same extent as the dura mater. This latter, 
when carefully examined, is seen to be composed of numerous con- 
centric layers, and is adherent on the outside to the vertebral ligament, 
and on the inside to the pia mater. 

Sometimes the thickened, hypertrophied membrane seems to be con- 
stituted of two layers ; the one external, the other internal. This last, 
which appears to be a new formation, consists of a dense fibroid tissue. 
It is, therefore, quite distinct from those soft and very vascular neo- 
membranes which, in the spinal as well as in the cerebral dura mater 
give rise to haematoma — constituting in the former the internal hasmor- 
rhagic pachymeningitis to be presently described. , 

The spinal cord itself participates in the alteration, which has all 
the characteristics of a transverse, irregularly disseminated myelitis, at 
tacking as well the central gray matter as the white columns. 

The peripheric nerves are affected by the spinal lesion, both in their 
radicles within the cord, and in their trunks, as they pass through the 
thickened and inflamed membranes. The anterior and posterior roots 
1 " De la pachymeningite cervicale hypertrophique," These de Paris, 1873. 



SPINAL MENINGITIS. 419 

are about equally involved, and hence, as symptoms, there are both 
derangements of motion and of sensibility. 

The symptoms, as given by Charcot, are, in the first place, extremely 
violent pains, which occupy mainly the posterior part of the neck, but 
which extend to the top of the head and to the superior extremities. 
These pains are accompanied with rigidity, especially marked in the 
neck, which is immobile, as in Pott's disease, occupying the sub-occip- 
ital region. They are generally quite constant, but are more violent 
at some times than at others. They extend to the joints, which, how- 
ever, are not ordinarily the seat of swelling, and with these pains there 
are the various sensations of numbness in the superior extremities, and 
some degree of paralysis. Sometimes there are bulbous and pemphi- 
goid eruptions. 

The second period is characterized by other symptoms, which appear 
to be due to the extension of the meningeal lesion to the spinal cord, 
and to a more profound alteration of the peripheric nerves. 

The limbs cease to be painful, but they become paralyzed, and the 
muscles are atrophied, and the atrophy extends to all the muscles of 
the extremity. But, speaking only of the muscles of the arm and fore- 
arm, it is notable that those which receive their innervation from the 
ulnar x and median nerve are especially affected, while those which are 
supplied by the radial nerve almost entirely escape. From this pecul- 

Fig. 32. 




iarity a certain character of deformity results, which, though met with 
in other diseases, and not always seen in the affection under notice, is, 
nevertheless, not a feature of other forms of muscular atrophy. It is, 
consequently, a diagnostic mark of some value (Fig. 32). To these 

1 M. Charcot says, du nerf radial el du nerf median, but it is evident from the con- 
text, as well as from what follows, that radial is a misprint for cubital (op. cit, p. 251). 
The cut also shows the error. 



420 DISEASES OF THE SPINAL CORD. 

symptoms are added contractions, and often anaesthesia, which may ex- 
tend from tlie extremities to the trunk. After a while, the inferior 
extremities become paralyzed, and eventually contractions ensue in 
them also. 

Charcot does not regard hypertrophic pachymeningitis as a neces- 
sarily incurable affection: for a woman, who, for five or six years, ex- 
hibited all its characteristic symptoms, being confined to her bed for a 
long period, recovered so far as to be able to walk and to use her hands 
in some labors. 

Internal hemorrhagic pachymeningitis is, in the spinal canal, the 
analogue of cerebral pachymeningitis or haematoma of the dura mater. 
Its differentiation from spinal meningitis was first made by Albers, 
though he failed to indicate its characteristic features. A. Meyer 1 first 
pointed out its essential nature. An officer had for some time been 
subject to vertigo, accessions of heat, and arterial throbbings, in the 
head and back. He recovered, but was subsequently seized with paral- 
ysis, mental derangement, incontinence of urine, and agonizing^ pains in 
the head. When these symptoms had lasted, with gradually-increasing 
intensity, for about a year, he died. The autopsy revealed the exist- 
ence of cerebral meningitis, and of a false membrane attached to the 
cranial dura mater, and to the same membrane in the vertebral canal as 
far down as the last dorsal vertebra. This membrane was fibrous, and 
composed of several laminae, between which were extravasations and 
masses of pigment. Other cases have been recorded by Magnan and 
Bouchereau, 2 as the result apparently of chronic alcoholism ; and by 
Charpy 8 and Simon, 4 as accompanying insanity and general paralysis. 

Internal haemorrhagic pachymeningitis is rarely unaccompanied by 
lesions of the brain, and is generally associated with the like intra- 
cranial disease. 

The morbid anatomy appears to differ in no essential respect from 
the analogous affection of the cranial dura mater, and the symptom- 
atology is not sufficiently characteristic to admit of its recognition 
during life. 

In cases of chronic spinal meningitis, due to syphilitic taint, the 
symptoms, as in the analogous condition of the cerebral membranes, are 
generally much more restricted, and may involve, as they usually do, 
the meninges in relation with the antero-lateral columns only. In such 
cases the lesion is presumably circumscribed, and the gummy exudation 
is likewise limited. The symptoms then relate almost entirely to the 
power of motion, either of one or both lower extremities, and there is 

1 Op. cit. 

3 " Memoires de la Societe de Biologie," 1869. 

8 Cited from unpublished notes, by Hayem, op. tit., p. 90. 

4 " Ueber den Zustand des Riickenmarks in der Dementia paralytica," Griesinger's 
Archiv, Heft 7 u. 2. 



SPINAL MENINGITIS. 421 

thus more or less extensive paraplegia. The lower dorsal and upper 
lumbar regions are, in my experience, almost the only parts of the cord 
attacked in such cases ; though I have occasionally witnessed instances 
in which the lesions were multiple, some of them being high up in the 
cord. 

In an interesting case, the details of which are very fully given by 
Jaccoud, 1 a man was paralyzed in both lower extremities. When the 
patient came under observation, the paraplegia had already lasted two 
months, and had been fully developed in three days : standing was im- 
possible, the right leg was more paralyzed than the left ; there were 
neither contractions nor atrophy ; there were no involuntary move- 
ments ; the motility of the trunk and superior extremities was perfect; 
electro-muscular excitability was not impaired ; tactile sensibility and 
sensibility to pain and heat were normal in the right inferior extremity; 
but in the left, though tactile sensibility was good, the sensibility to 
pain and heat was impaired ; indeed, the sensation to impressions, ordi- 
narily painful, was entirely lost throughout the whole extent of the limb. 

In regard further to the case of which I have given but a brief 
abstract, M. Jaccoud remarks : 

" The nature of the lesion can be very easily determined. The para- 
plegia was developed in three days, in an apparently healthy man. There 
had been no fever, pains, sensation of constriction, convulsions, or con- 
tractions. The lesion was very limited, the portion of the cord situated 
above was not altered, and the morbid process involved one side more 
than the other. I know of no condition which fulfills all these phe- 
nomena but compression of the cord. Paraplegia of rapid invasion is 
observed, it is true, in acute myelitis, in acute meningitis, in spinal 
haemorrhage, in meningeal spinal congestion, and in hydrorachis; but it 
is then accompanied with fever or pain, symptoms which have been 
entirely absent in our patient. Moreover, these lesions do not produce 
so limited a disorder as that before' us. The compression of the cord 
in this case is from before backward, and the anterior columns are more 
affected than the posterior; but on the right side the compression has 
involved the gray sensory elements of the posterior spinal system, 
leading to loss of thermic and painful sensibility in the left lower ex- 
tremity. 

" Such is the pathogenetic diagnosis of our paraplegic patient ; it is 
founded entirely on the physiological interpretation of the symptoms; 
and, as the case is very strongly marked, analysis permits us to notice 
a 11 the particularities of the lesion of the cord. You can ask nothing 
more complete; it is a physiological diagnosis par excellence / it is per- 
fect. Here, gentlemen, appears the superiority of medical over physio- 
logical diagnosis ; and I am happy that this occasion permits me to 

1 " Le9ons de clinique medicale faites a l'Hopital de la Charite," deuxieme edition, 
Paris, 1869, p. 446. 



422 DISEASES OF THE SPINAL CORD. 

insist upon your appreciation of this capital truth, that others hava 
vainly opposed. What does this very exact physiological diagnosis 
teach us in regard to the prognosis ? Nothing, absolutely nothing ; it 
is a dead letter. Our patient has a compression of the cord at the 
tenth dorsal vertebra. This compression is stronger on the right than 
on the left side; it has interrupted the conductibility of the motor col- 
umns of the cord on both sides, and of the sensory columns on the 
right side, but it has not interfered with the posterior white columns, 
or the two orders of nerve-roots. But, knowing all this, are we the 
better enabled to be of use to our patient, who cares only for one 
thing, and that is the recovery of the use of his legs ? No ! a thousand 
times no ! These scientific data, acquired with such labor, are sterile, 
and our physiological diagnosis is powerless to help us. It teaches us 
nothing relative to the probable issue of the disease; nothing touching 
the treatment to be employed. But let us substitute the physician for 
the physiologist; let us bring the principles of clinical diagnosis to bear 
upon the subject, and we shall discover something of the future of the 
patient, and how we are to treat him. This man is syphilitic, and that 
one word, which is the index of the medical diagnosis, at the same time 
points out to us the nature of the compression which the cord is under- 
going, reveals the prognosis of the paraplegia, and directs us as to the 
treatment to be employed. 

" This patient has, up to this time, had none of the accidents called 
secondary; he certainly has not yet reached the tertiary stage; at most 
we can only say that he has arrived at that transition stage which often 
separates superficial from profound syphilitic determinations. He pre- 
sents no visible lesion of the bones, and in that situation we could only 
allege an exostosis or a vertebral periostitis as a cause of the compres- 
sion of the cord. I am more inclined to believe that the lesion is one 
of those meningeal affections of the kind described by Knorre, 1 con- 
sisting in circumscribed exudations, which may remain latent if they 
are very small, but which, if large, may cause compression and conse- 
quent paraplegia." 

The patient ultimately recovered, under the use of the bichloride of 
mercury and the iodide of potassium. 

A case, very nearly identical in its chief features with that of M. 
Jaccoud, came under my care a few months since, in consultation with 
Dr. Van Wyck, of this city, in which recovery was complete under like 
treatment. 

In relation to these exudations of the spinal membranes, Vir- 
chow 3 declares that little is known of their morbid anatomy ; and 
Charcot 3 asserts that they are not common — basing his opinion, how- 

1 " Ueber syphilitische Lahmungen," Deutsche Elinik, 1849. 

* " Pathologie des tumeurs," Paris, 1869, tome ii., p. 454. 

8 " Lecons sur les maladies du systeme nerveux," deuxieme partie, second fasci- 
cule, p. 80. 



SPINAL MENINGITIS. 423 

ever, only on the small number of post-mortem examinations which 
have been made, in which these formations have been found A parity 
of reasoning would throw hysteria, for instance, out of nosology alto- 
gether. We are not likely to have much information in regard to the 
morbid anatomy of so curable a disease as syphilitic spinal meningitis. 
So far as our information extends, the condition induced in the spinal 
membranes by syphilids does not differ essentially from that caused by 
the same influence in the cerebral membranes, and which has been fully 
considered in the present work under the head of basilar cerebral 
meningitis. In this view I am supported by Buzzard, 1 Lagneau, 2 Gros 
and Lancereaux, 3 Zambaco, 4 and others. 

The theory of the symptoms observed in spinal meningitis is, that 
they are due to two immediate causes, excitation and pressure. The 
former is the result of the hyperaemia, the latter of the exudation, 
or of the increased amount of spinal fluid causing pressure. 

Treatment. — In the acute form of spinal meningitis, active meas- 
ures are required. The application of leeches to the painful part of the 
spine, or of cups, so as to effect local depletion, will generally prove 
useful. Hydragogue cathartics are also beneficial, for by their action 
the vessels of the inflamed membranes are depleted of their blood, and 
the excessive amount of spinal fluid effused is in consequence more 
readily absorbed. 

Mercury may also be advantageously administered either by inunc- 
tions with mercurial ointment or by calomel given internally, or by both 
these means. Calomel should be given in doses of from one to two 
grains every three or four hours, till the system is brought under its 
influence, as manifested by fetor of the breath. 

The patient should be kept as quiet as possible, and should be en- 
joined not to lie on the back. For the relief of the dorsal and other 
pains, suppositories, containing each, half a grain of codeine, are often 
efficacious. They may be administered night and morning. 

In the chronic form of the disease, depletion by bloodletting in any 
form is not so beneficial as in the acute variety or as in spinal conges- 
tion. Blisters are more admissible, and scarcely ever fail to do good. 
They should be applied on each side of the spinal column near the 
diseased region of the cord, and as soon as one heals another should 
take its place. Purgatives are also useful for the same reasons which 
prevail in acute spinal meningitis. 

Iodide of potassium is always a valuable agent, indeed more so than 
any other remedy employed in chronic spinal meningitis. I employ it 

1 " Clinical Aspects of Syphilitic Nervous Affections," London, 1874, p. 70. 

2 "Maladies syphilitiques du systeme nerveux," Paris, 1860. 
9 " Des affections nerveuses syphilitiques," Paris, 1861. 

* Ibid., Paris, 1862. 



424 DISEASES OF THE SPINAL CORD 

in the foim of a saturated solution, which contains about a grain to 
each drop. Of this, I administer the first day seven drops three times, 
preferably before meals; the next day eight drops to the dose, the next 
nine, and so on, till the patient takes from forty to sixty drops at the 
dose, according to circumstances. The iodide of potassium always acts 
best when largely diluted with water, so that, as the doses are increased, 
an additional quantity of water should be used. 

I very often employ the corrosive chloride of mercury in combina- 
tion with the iodide of potassium, in doses of the sixteenth of a grain 
with each dose of the iodide. 

The treatment with iodide of potassium and mercury is still moie 
strongly indicated in those cases which are of syphilitic origin. 

Diuretics may also frequently be given with advantage. Their 
object is the same as that which governs in the administration of 
purgatives. 

In two of the cases cured, to which reference has been made, I 
derived the greatest benefit from repeated blisters, and the persistent 
use of iodide of potassium. The latter was carried to the extent of 
fifty grains three times a day in one of these cases, and sixty -five in 
the other. 

At the same time the primary galvanic current was applied to the 
spine in the manner recommended for spinal congestion, and the in- 
duced current to the paralyzed limbs. I am very sure that electricity 
in both these forms should be used in most cases of chronic spinal 
meningitis. The following case, reported by J. Frank, 1 and quoted by 
Ollivier, 3 of acute spinal meningitis, is instructive: 

"A captain, aged forty-two years, of sanguineo-bilious tempera- 
ment, subject to rheumatic pains and haemorrhoids, and addicted to the 
use of alcoholic liquors, was suddenly seized on the evening of the 2d 
of March, 1819, with a chill, which was soon succeeded by a burning 
fever, accompanied by pain in the lumbar region. During the night 
the pain increased, extended as high up as the occipital region, and 
gradually acquired great intensity. J. Frank was called in the morning 
at five o'clock, to see the patient, who was suffering acutely. He was 
uttering loud groans, was lying on his belly, with the superior and in- 
ferior extremities stretched out to their full length. To the questions 
put to him, the patient answered with great difficulty that he had pains 
all over his body, that he was unable to open his eyes, that his teeth 
were strongly clinched, and that a burning and pulsating pain extended 
from the occiput to the lower extremity of the vertebral column. The 
limbs, especially the inferior, were without sensation, but were agitated 
by occasional jerkings. There was such a constriction of the chest that 
breathing was scarcely possible, and the abdomen was likewise in a 

1 " Praxeos Med., etc., de rachialgite," tome vi., p. f6, Turin, 1 822. 
' Op. cit, d. 295. 



SPINAL MENINGITIS. 425 

state of contraction. There were constipation, incontinence of urine, a 
pulse soft but 100 per minute, occasional palpitations of the heart, and 
a hot and dry skin. 

" Frank at once opened a vein in the foot, and abstracted sixteen 
ounces of blood. A dozen leeches were applied around the occiput, 
and as many scarified cups on each side of the spine. A decoction of 
tamarinds was given as a cathartic. These means were sufficient to 
restore the health of the patient in a few days. The bloodletting pro- 
duced an almost immediate cessation of all the symptoms ; for, a short 
time after its employment, the movement of the eyelids became easy, 
as well as that of the jaw; sensation reappeared in the extremities, and 
the dorsal pain diminished considerably in intensity." 

As Ollivier remarks in regard to this case, several of the symptoms 
are those of spinal congestion. The sudden supervention of the disease, 
as well as its rapid disappearance, points to that affection. Nevertheless, 
its general features are those of acute spinal meningitis — an affection 
which, of course, cannot exist without congestion. 

In a very interesting case under my charge several months ago, a 
cure of the spinal disorder, which was chronic spinal meningitis prob- 
ably of syphilitic origin, was accomplished by the use of the iodide of 
potassium and the corrosive chloride of mercury, as recommended on 
pages 449 and 450. In this case the affection had lasted for several 
years, and extended from the occiput to the lower extremity of the 
spinal coid. The limbs were constantly subject to violent spasmodic 
jerkings, and both legs and one arm were in a permanent state of con- 
traction, which had existed for three years. Under the use of the iodide 
and the mercury, as mentioned, the pain, which had been intense, 
ceased, the spasms of the limbs were stopped, the bladder regained its 
expulsive power, the bowels again began to act without purgatives or 
injections being required, and the limbs could be moved as extensively 
as the rigid contractions permitted. These had existed so long that the 
flexor muscles had become much shortened, and the skin in the groins 
and popliteal spaces was tense and unyielding. The accompanying 
woodcut (Fig. 33) shows the positions of the legs and arm at this time. 
Under these circumstances I requested the advice of my friend Prof. 
L. A. Sayre, and after consultation it was determined to divide the 
tendons of the tensor vaginae femoris, the sartorius, the gracilis, and 
the biceps, on each side. When this was done by Prof. Sayre, the 
patient being under chloroform, careful but powerful efforts at exten- 
sion were made, and the skin in the popliteal space on both sides was 
necessarily torn, owing to its contraction and inelasticity ; the limbs 
were thus brought into a state of complete extension, and, by a syst2m 
of weights and pulleys similar to that used in Buck's fracture apparatus, 
they were kept in this position. The patient was, however, too weak 
to endure the fatigue of the necessary extension and confinement. He 



426 



DISEASES OF THE SPINAL CORD. 




SPINAL MENINGITIS. 427 

took off the weights whenever they caused pain or great uneasiness. 
To add to the difficulties, a large bed-sore formed on the right buttock, 
and the strength of the patient declined so rapidly that, in order to 
save his life, the apparatus had to be entirely removed. He rapidly re- 
covered, but, as cicatrization went on, the limbs again became con- 
tracted, and in the course of two or three months were as bad as ever. 
Pain in the back soon afterward supervened, the legs and one arm 
began to be affected with spasms, and the paralysis also returned. A 
renewal of the former medication again caused relief, and the patient 
has to this day remained free from any spinal disease, though his legs 
are still contracted. This is the third case of cure referred to as hap- 
pening in my experience. 

For the cure of the bed-sores the method recommended by Dr. 
Brown-Sequard may be used. It consists in the alternate application 
of sponges, one of which is saturated with hot water and the other with 
cold water. This should be done for five or ten minutes every day, and 
the effect is to increase the activity of the circulation of the part, and 
to promote the formation of granulations. 

But I have generally preferred the method by galvanism first sug- 
gested and employed by Crussel, 1 of St. Petersburg, and which I used 
for the treatment of indolent ulcers with almost invariable success, in 
1859, when surgeon to the Baltimore Infirmary. The method was also 
recommended by Mr. Spencer Wells. 3 During the last twelve years I 
have employed it to a great extent in the treatment of bed-sores caused 
by diseases of the spinal cord, and with scarcely a failure — indeed, I may 
say without any failure except in two cases where deep sinuses had 
formed which could not be reached by the apparatus. 

A thin silver plate, no thicker than a sheet of paper, is cut to the 
exact size and shape of the bed-sore. A zinc plate of about the same 
size is connected with the silver plate by a fine silver or copper wire six 
or eight inches in length. The silver plate is then placed in immediate 
contact with the bed-sore, and the zinc plate on some part of the skin 
above — a piece of chamois-skin, soaked in vinegar, intervening. This 
must be kept moist, or there is little or no action of the battery. 
Within a few hours the effect is perceptible, and in a day or two the 
cure is complete in the great majority of cases. In a few instances a 
longer time is required. I have frequently seen bed-sores three or four 
inches in diameter, and half an inch deep, heal entirely over in forty- 
eight hours. Mr. Spencer Wells states that he has often witnessed 
large ulcers covered with granulations within twenty-four hours, and 
completely filled up and cicatrization begun in forty-eight hours. 

1 Neue Med.-Chirurg. Ztitxing, No. 7, 1847, p. 235. 

2 " Lectures on Electricity and Galvanism," by Dr. Golding Bird, London, 1849, ap- 
pendix. There is an American edition of this very interesting little book, but it has long 
been out of print. 



428 DISEASES OF THE SPINAL CORD. 

During his recent visit to this country I informed him of my experi- 
ence, and he reiterated his opinion that it was the best of all methods 
for treating ulcers of indolent character and bed-sores. 

Ergot is not so generally useful as in congestion, though I rarely 
fail to give it at some time or other in cases of chronic meningitis, with 
a view to the relief of the accompanying congestion. Strychnia is not 
at all admissible at any time. Reeves ' recommends it in those cases in 
which pains, cramps, and contractions, are absent, but I have never 
seen such cases. Indeed, a case in which they were not prominent 
symptoms could scarcely be regarded as one of spinal meningitis. 

In the meningitis and myelitis resulting from Pott's disease, the 
actual cautery is of inestimable value. Its efficacy has been very 
strongly insisted on by Charcot and Michaud, both of whom give cases 
in illustration of its value. Within the last year I have treated five 
cases of this complication with the agent in question, and with benefi- 
cial results in all. It is an error to suppose that the paraplegia so gen- 
erally attendant in the vertebral disease is the result of the compression 
of the cord. For there maybe paraplegia — as I had the opportunity of 
seeing quite recently in a case of Pott's disease under the care of Dr. 
F. D. Lente, of Cold Spring, and in which I was consulted, when there 
is no deformity whatever ; and the paraplegia may disappear, the 
curvature remaining undiminished. This was the case in a patient sent 
to me by Dr. Butler, of Baltimore, who had been the subject of Pott's 
disease several years previously, and who had recovered, with very 
great curvature, but without paralysis. A few weeks, however, before 
coming under my observation, the paraplegia had returned, the curva- 
ture remaining the same. Cruveilhier, as Charcot reminds us, pointed 
out, long ago, the fact that the spine may be the seat of the most ex- 
traordinary deformities without the cord being compressed. 

In a lecture delivered at the Salp§triere, M. Charcot 2 related the 
case of a young Polish girl affected with Pott's disease, complicated 
with paraplegia, who left Warsaw to consult him, but who, on her way 
to Paris, stopped in Berlin, to obtain Langenbeck's advice. The great 
German surgeon counseled her not to allow the cautery to be used, 
but she, nevertheless, proceeded to Paris. After the second cauteriza- 
tion she walked, and fifteen days subsequently she paid a second visit 
to Langenbeck, " furnishing to him," as the reporter remarks, " an 
irrefragable proof that empiricism is a good thing, when it is accepted 
and recommended by men of science." 

The number of cauterizations need not exceed five or six, and they 
are best made with the disk-ending iron with platinum tip, which should 
be applied at several points on each side of the diseased vertebrae. 

1 " Diseases of the Spinal Cord and its Membranes, and the Various Forms of Paraly- 
sis arising therefrom," London, 1858, p. 55. 

8 GazetU Medicale de Paris, 5 Decembre, 1874. 



ACUTE MYELITIS. 429 

CHAPTER V. 

THE INFLAMMATIONS OF THE SPINAL CORD. 

The subject of inflammation of the spinal cord has, within the last 
iew years, been so greatly amplified in all its details by those eminent 
French pathologists, Charcot and Vulpian, and their pupils, and so 
much exact information has been obtained through their investigations, 
that the arrangement followed in the previous editions of this work, 
based on the morbid anatomy, as then known, no longer represents the 
actual state of the science. I shall, therefore, consider the inflamma- 
tory affections of the spinal cord according to a plan somewhat modified 
from the systematic table of Clement * — a table constructed from the 
most recent data furnished by the authorities above mentioned. In so 
doing, I shall omit those disorders which have only a theoretical exist- 
ence, or which, in my opinion, have been, on insufficient data, assigned 
a definite patho-anatomical position. 

I. 

ACUTE MYELITIS. 

a. Acute General Myelitis. 

In acute general myelitis the whole extent of the cord is involved 
in the morbid process. 

Symptoms. — The onset of the disease is sudden. A chill is generally 
the first symptom observed, and this is followed immediately by high 
febrile excitement, during which the pulse may be as frequent as 160 
per minute. The temperature of the body is slightly elevated, but 
rarely reaches 103°Fahr. Alterations of sensibility and motility are 
noticed with the inception of the fever. 

Among the first, pain in the back is prominent. This is usually 
most severe in the dorsal region, and is aggravated by percussion and 
by the passage of a sponge saturated with hot water, or one with cold 
water, over the affected region. It is not, however, so intense in char- 
acter as that attendant on acute spinal meningitis, and it is not in- 
creased by movements of the limbs or of the vertebral column, in which 
respects it differs from the pain due to this last-named disease. 

In addition, there are various derangements of the cutaneous sensi- 
bility in those parts of the skin below the seat of the disease. These 
consist of formication, " pins and needles," a sensation as if water were 
trickling over the skin, as if the limb were asleep, and of sensations of 
cold or heat. Anaesthesia is the most common general condition of the 
skin, and it is often accompanied with cutaneous pains, which are the 

5 " Note sur les my&ites d'apres les travaux fran^ais recents," Paris, 1875, p. t. 



430 DISEASES OF THE SPINAL CORD. 

more intense the more profound is the anaesthesia. Thus, if we have 
ascertained that the cutaneous sensibility is very much impaired at a 
particular spot, we will frequently find this spot the seat of severe and 
spontaneous pains. In such cases, too, a prick with a pin is felt, but 
the ability to distinguish the two points of the aesthesiometer is lost, 
even when they are widely separated. Indeed, they may not be felt at 
all unless they are so used as to cause pain. I have several times ob- 
served patients whose tactile sensibility was almost entirely gone, but 
whose sensibility to pain was so great that they could not endure the 
contact of the bedclothes. The distinction, therefore, between insensi- 
bility to touch — generally called anaesthesia — and insensibility to pain 
— analgesia — must be clearly made. 

A sensation of constriction around the body is sometimes experi- 
enced, and the limbs are likewise often the seat of a like symptom, 
giving the impression to the patient that they are encircled by tight 
cords or incased in closely-fitting armor. 

Hyperaesthesia is occasionally present, but probably not unless there 
is meningitis associated with the myelitis. 

Motility is affected at a very early period of the disease, and at first 
consists of simple twitchings of the muscles, and paralysis. The latter 
comes on with great rapidity, and may become complete in a few hours. 
Jaccoud ' states that he has seen this result produced in thirty-six hours, 
and Ollivier 2 cites several cases to the same effect. The bladder is 
almost invariably paralyzed, as are also its sphincter and that of the 
anus. There is, therefore, dribbling of the urine, and the faeces are 
evacuated involuntarily as soon as they pass into the rectum. 

Reflex excitability is entirely abolished in acute general myelitis. 
Tickling the sole of the foot, therefore, fails to produce any movement. 

Electro-muscular contractility is diminished, unless, perhaps, in the 
very earliest stage of the affection, and the " reactions of degenera- 
tion " are well marked. There is always a tendency to rapid atrophy 
of the paralyzed muscles. 

The temperature of the affected limbs begins to fall from the very 
first, and may be diminished by as much as 3° Fahr. Sloughs and bed- 
sores make their appearance about the sixth day, though I have several 
times seen them form at a much earlier period. Although they occur 
in those parts of the body — as the sacrum, nates, and hips — which are 
subject to pressure, it is very certain that the decubitus is not their 
primary cause. In three instances I have had them result, in cases under 
my charge, within twenty-four hours after the inception of the disease. 

Besides the foregoing symptoms, there are others referable to the 
viscera, and which may occur almost simultaneously, or in marked 
sequence, as the morbid process extends through the length of the 

1 Op. at, p. 318. 

2 Op. cit., chap, huitieme, " Mj* elite, ou inflammation de la moelle epiniere." 



ACUTE 1TYELITIS. 431 

cord. Thus, there may be frequent and almost constant painful erec- 
tions, vomiting, derangement of the liver, irregular action of the heart, 
difficult respiration, and more or less impairment of the faculty of swal- 
lowing. The voice may be abolished, and the muscles of articulation 
be so far paralyzed as to render even a whisper impossible. 

The urine is often, if not invariably, alkaline. This is not the result 
of contact with the mucus retained in the paralyzed bladder, for, if this 
organ be thoroughly cleansed with water, the urine collected from it 
with a catheter is found to be of alkaline reaction. This alkalinity is 
doubtless due to the presence of an excessive proportion of the ammo- 
nio-magnesian phosphates. 

The quantity of urine is diminished, and albumen, pus, or blood, may 
be present in it, besides the large amount of vesical mucus which is so 
prominent a constituent. 

Acute general myelitis ordinarily runs its course in about ten days, 
though it may terminate in death in a much shorter period, or be pro- 
longed for several weeks. Death is due either to asphyxia or exhaus- 
tion. The former result is obtained when the inflammation reaches the 
upper cervical region, and the muscles of respiration become paralyzed, 
or the action of the heart greatly interfered with. In consequence of 
the paralysis of these muscles and of those concerned in deglutition, 
mucus accumulates in the air-passages and pharynx, and may lead to 
sudden asphyxia. 

Such is a general view of the symptomatology of acute general 
myelitis, when the whole or greater part of the spinal cord is involved. 
It is not, however, to be supposed that the phenomena are all present 
at the same time. Such a condition very rarely exists. As a rule, the 
inflammation advances from below upward, and the symptoms occur in 
order as the morbid action progresses. Sometimes, however, the cen- 
tral region of the cord is first attacked, and the extension takes place 
in both directions. 

b. Acute Partial Myelitis. 

In this form of the affection the inflammation is restricted to a 
limited portion of the cord, and, as a consequence, the symptoms are 
less profound and extensive than in the general form. The morbid 
process may be confined to a very small part of the cord, or may involve 
the cervical, dorsal, or lumbar regions, with, of course, some variation ir> 
the symptoms, according to the situation. 

Symptoms. — The pain in the back is similar to that experienced in 
the general form, and it is, like that, excited or aggravated by percus- 
sion or by the passage of a sponge saturated with very hot or cold wate* 
over the affected locality. 

The aberrations of sensibility are less strongly marked, but, on ac- 
count of the slower progress of the disease, they are of longer duration. 



432 DISEASES OF THE SPINAL CORD. 

In a case now under my charge, and in which there is the pain in the 
spine, presenting the above-mentioned characteristics, the patient, a 
gentleman about thirty years of age, has, in addition to these marked 
symptoms, nearly absolute anaesthesia in the left lower extremity, 
which existed as the only phenomenon of any moment for three or four 
weeks. 

The sense of constriction around the body is generally but not 
always present, and its seat marks the upper limit of the inflammation. 

Another symptom, often noticed, is one to which Charcot has called 
special attention, and that is, the inability of the patient to localize his 
sensations. Sometimes this is surprisingly manifested. In a patient 
whom I -brought at my clinique before the class of the University Med- 
ical College, a prick of a pin made in the right thigh was referred to 
the left thigh, and one made on the left foot was felt on the left knee. 
So far as the intensity of the sensation was concerned, it was as great 
as, if not greater than, in health. This is not an unusual circumstance. 
In a case cited by Charcot, 1 the sensibility to cold, to contact, and to 
tickling, was abolished, and yet, when the patient was pinched, an 
acute sensation of pain was experienced. This pain was accompanied 
by spinal symptoms : 

1. There was error as regarded location: the leg was pinched, but the 
pain was referred to the hip, then to the opposite hip, and, finally, to the 
whole length of both limbs. 

2. The sensation was assimilated to a vibration or a trembling. 

3. It was the same for the different methods of excitation ; it not 
only ensued on pinching, but on the application of cold. 

4. It lasted during a quarter of an hour, and sometimes longer. 

5. Sometimes it was not perceived till an appreciable interval of 
time had elapsed. In a case cited by Romberg, this interval was thirty 
seconds. 2 

As Charcot says, this delay in appreciating sensations is due to a 
profound lesion of the gray substance of the cord. 

The paralysis of motion observed in partial acute myelitis is less 
extensive than that which exists in the general form of the disease. In 
the early stages there are convulsive movements in the muscles sup- 
plied by the nerves, having their origin in the affected portion of the 
eord; but, eventually, the loss of power becomes more or less complete. 
It may at no time, if the lesion be very circumscribed, extend beyond 
the point of slight diminution. 

The reflex excitability is generally augmented. In a case now under 
my charge, in which the morbid process apparently only involves a seg- 
ment of the cord in the lower dorsal region, the slightest touch of the 

1 Dujardin-Beaumetz, " De la myelite aigue," Paris, 1872, p. 121. 
* In a case of locomotor ataxia under my own care, to be cited more particularly 
farther on, this retardation amounted to several minutes. 



ACUTE MYELITIS. 433 

lower extremities is followed by movements as intense as those in 
tetanus. Charcot, as stated by Dujardin-Beaumetz, arranges the phe- 
nomena under this head into two classes : that in which there is a 
simple exaggeration of the spinal excitability, and that in which there 
is the continuance of the spasms, which are, in my opinion, improperly 
designated spinal epilepsy. This spinal epilepsy may appear under 
two forms : either as tetaniform or tonic convulsions, or as saltatory 
cramps — clonic convulsions. In several cases I have witnessed both of 
these types in the same individual. 

It is not often the case that bed-sores, or other forms of ulceration 
and death of the soft parts, occur in acute partial myelitis, except in 
those cases which have a traumatic origin — they are generally rapidly 
developed. It is not uncommon, however, to witness atrophy of the 
paralyzed muscles, more or less extensive and complete, according to 
the extent and profundity of the lesion of the cord. 

The temperature of the parts supplied by the nerves coming from 
the affected region of the cord is, perhaps, in the first place, somewhat 
increased. Eventually, however, as the paralysis of sensibility and mo- 
tion becomes more strongly marked, there is a decided fall. By means 
of Dr. Lombard's thermo-electric differential calorimeter, comparative 
results can be simultaneously obtained with great ease and exactness. 

The electric excitability of the paralyzed parts is always lessened. 

The symptoms of acute partial myelitis are, of course, different, ac- 
cording as the cervical, dorsal, or lumbar region, is the seat of the mor- 
bid action. For convenience of description, the cord may be divided 
into two parts : the cervico-dorsal, embracing the cervical region and 
the dorsal as far as the sixth dorsal vertebra ; and the lumbo-dorsal, 
comprehending the remaining part of the cord. 

When the lesion involves the cervico-dorsal region, the upper ex- 
tremities may be paralyzed without the lower participating; but dis- 
turbances of sensibility are generally experienced in all parts situated 
below the seat of disease. If the upper part of this division be affected 
there are difficulty of swallowing, disturbances of the respiration and 
circulation, and gastric derangement. The pupils are at first dilated, 
and subsequently contracted. Epileptic convulsions are occasionally an 
accompaniment. There may be, as I have seen in two cases, accessions 
of great venereal excitement. 

When the dorso-lumbar region is the part affected, the lower ex- 
tremities alone exhibit aberrations of sensibility and motility. The 
sense of constriction is generally felt, and the bladder and rectum are 
usually paralyzed. 

Acute partial myelitis is much slower in its progress than the gen- 
eral form of the disease, and life may be prolonged for a considerable 
period if the lesion be not very extensive. 

Causes. — Acute myelitis, whether of the general or partial form, is 
29 



434 DISEASES OF THE SPINAL CORD. 

more frequently the result of injury than of any other cause. It is 
likewise a sequence of disease of the vertebrae, extending to the dura 
mater and other membranes, and of meningitis. It is also said to be 
produced by exposure to extreme heat or cold, by violent muscular 
efforts, and by venereal excesses. Twelve cases have come under my 
observation. Of these, three were the result of wounds, two ensued on 
disease of the vertebrae, three on exposure to intense cold, two were 
apparently due to excessive muscular exertion, and two were caused by 
extension of acute meningitis. 

Diagnosis. — The principal diagnostic marks of acute myelitis are 
the occurrence of the sensation of constriction around the body, the 
alkalinity of the urine, the rapid supervention and the completeness 
of the paralysis, the great predisposition to sloughs wherever there is 
the least pressure, the excitation of pain in one part of the body by 
irritation applied to some other part, the causation of reflex movements 
in a similar way, the speedy loss of electric contractility, and the 
marked depression of temperature in the paralyzed parts. 

From acute meningitis it is distinguished by the fact that the pain 
in this disease is more severe, that it is aggravated by movements of 
the spine, and that there are marked, and sometimes permanent, con- 
tractions of the limbs. The paralysis is never so profound. Moreover, 
bed-sores and atrophies are not phenomena met with, except as the 
results of long-continued pressure in the one case and of disuse in the 
other. 

In congestion of the cord the symptoms are less strongly pro- 
nounced, and are more or less subject to remissions ; bed-sores are un- 
common ; the progress of the disease is slower, and the symptoms are 
aggravated when the patient assumes the recumbent posture, and the 
urine is not alkaline, except as the consequence of paralysis of the 
bladder. 

From haemorrhage of the cord the diagnosis is not, in general, a 
matter of doubt, but the following case, reported by Dujardin-Beau- 
metz, would seem to present an exception to this statement : 

" A porter, while at his work, was suddenly seized with complete 
paralysis of motion and sensibility of all parts of His body, except the 
head and neck. There was no loss of consciousness. The bladder and 
rectum were paralyzed ; there were no contractions ; the respiration 
was slow and painful, the diaphragm alone, of all the respiratory mus- 
cles, being active. The intelligence was perfect. The diagnosis was 
haemorrhage of the cord at about the junction of the cervical with the 
dorsal portion. Three days after the accession the patient died as- 
phyxiated. On post-mortem examination, no trace of haemorrhage 
could be found, but the cord was softened and completely broken up at 
the dorsal enlargement." 

The diagnosis from hysteria may sometimes require to be made. 



ACUTE MYELITIS. 435 

As is well known, this condition may simulate almost every affection of 
the nervous system, and acute inflammation of the cord is not one of 
the exceptions. The pain in the back, the constriction around the 
body, the paraplegia, the cystic and rectal derangements, the anes- 
thesia as met with in acute myelitis, may all be due to hysteria. But 
careful examination will serve to make the discrimination easy and 
complete. The symptoms are exaggerated, and are not constant, the 
general disturbance of the system is slight, there is no progressive ad- 
vance of the disease, and the patient, nearly always of the female sex, 
exhibits the history and diathesis of hysteria so unmistakably, that 
error is rendered almost out of the question. 

Prognosis. — The termination of general acute myelitis is in death 
sooner or later. Even if it passes into the chronic stage, the altera- 
tions in the structure of the cord are so extensive as to be incompatible 
with the performance of its functions. Death was the result in all 
the cases that I have personally observed, and this event occurred in all 
within three weeks. 

In partial acute myelitis recovery is not impossible, although even 
in this form the prognosis is grave, and the life of the patient, if saved, 
is always at the expense of the sensibility and motility of the parts 
below the seat of the lesion. 

Even then, in many cases, disease of the bladder, and other second- 
ary affections shorten the term of existence. 

Morbid Anatomy and Pathology.— In acute general myelitis the 
whole cord is involved in the morbid action, and exhibits a more or less 
considerable enlargement throughout its entire length. As both the 
white and gray substances are implicated, both become broken down by 
softening, and hence it is impossible to distinguish one from the other. 
It appears, however, to be extremely probable that originally the mor- 
bid process is parenchymatous, that is, confined to the true cell-ele- 
ments of the cord, and that the neuroglia is subsequently attacked. 
Extravasations of blood are met with throughout the medullary tissue. 
The membranes are sometimes adherent to the cord at various points, 
or there may be puriform accumulations between them and the cord. 
At other times the pus is found in isolated depots or in canals extend- 
ing through the entire length of the nerve-substance. The tendency 
is to a still more decided condition of softening, and eventually a stage 
is reached in which the cord is reduced to a semi-liquid state. 

The inflammation in cases of acute partial myelitis may be limited 
to the white substance or to the gray substance, or may attack both 
these tissues. It may likewise affect the antero-lateral columns, the 
posterior, or extend to both. Undoubtedly, if we had sufficient oppor- 
tunities to witness cases of spontaneous origin not the result of trau- 
matic causes, or of the extension of other diseases, we should be enabled 
to distinguish by the symptoms which part of the cord histologically or 



436 DISEASES OF THE SPINAL CORD. 

topographically is affected. For there can be no doubt that, as in 
anaemia, or as we shall see hereafter in certain acute and chronic forms 
of myelitis, the symptoms must be as characteristic as are the functions 
of the several histological and regional parts of the cord. 

As regards the obvious morbid anatomical features, we find that 
when the lesion is situated in the white substance the membranes of 
the affected portion are congested, thickened, opaque in patches, and 
adherent to the cord. The cord is softened to a variable depth, and 
this portion is detached with the membranes if these be removed. This 
softened portion is in the early stage rose-colored and studded with red 
points, marking the situation of the enlarged blood-vessels. As the 
disease advances, the color deepens to a reddish-brown, then begins to 
get lighter, and, passing through several shades of yellow, eventually 
becomes white. 

When the gray substance is involved, the changes in its physical 
appearance are similar ; and, when both the white and the gray are the 
seat of the morbid process, it is impossible to distinguish the two sub- 
stances from each other. 

Microscopical examination shows the existence of congestion, and, 
as an essential feature, an increase in the amount of connective tissue 
or neuroglia of the cord. The evidences of this hypertrophy are seen 
in the increase of fusiform cells and in the production of multinuclear 
cells and free nuclei. These formations take place at the expense of 
the proper nervous tissue of the cord, the anatomical elements of which 
undergo atrophy and fatty degeneration. The nervous tubules are thus 
often disintegrated and their contents disseminated through the extra- 
neous tissue. The axis cylinders are entirely surrounded by oil-glob- 
ules, or are altogether broken up and rendered unrecognizable. 

Should suppuration occur, the elements of pus are observed among 
those already described, and take their place to a considerable extent. 

In case of the passage of acute myelitis into the chronic form, the 
centre of inflammation usually undergoes other changes, which, how- 
ever, still maintain the general characteristic of hypertrophy of the 
neuroglia at the expense of the proper nervous tissue. Induration, or, 
as it is now generally called, sclerosis, is the result. Occasionally, how- 
ever, the softening persists and becomes the permanent structural con- 
dition of the diseased portion of the cord. 

When the lesion is in the gray substance, the microscope shows the 
nervous cells to be broken up, and the anatomical elements of the blood 
to be scattered through the tissue. 

Treatment. — The treatment of acute general myelitis offers no en- 
couraging features. The most that can be done is to endeavor to 
prevent, as far as possible, the formation of sloughs, by placing the 
patient on a water-bed, and by sponging the parts exposed to pressure, 
with whiskey or with hot and cold water alternately applied. The treat- 



ACUTE MYELITIS. 437 

mont generally does not differ from that recommended in acute menin- 
gitis, the indications being almost identical. So far ~s my experience 
extends I have never found any means sufficient for cure, ana the few 
successful instances that have been reported are doubtless, as Jaccoucl 
suggests, cases of congestion or meningitis. 

But in the partial form of the disease there is some hope of being 
able to arrest the morbid process, or at least to prevent its extension to 
the sound parts of the cord. Some authors have recommended mer- 
curials, but I do not perceive any indication for their use. I am satis- 
fied, however, that I have derived decided benefit from the administra- 
tion of ergot in large doses, as recommended for congestion, and from 
the employment of revulsives. Of these latter agents the actual cautery 
occupies the first place. It should be applied either in the form of 
longitudinal lines on each side of the vertebral column at the seat of 
the lesion, or as points, to the number of three or four, similarly situated. 
The skin should be rendered anaesthetic by the ether-spray before the 
application of the heated metal, and this latter should be platinum, 
brought to a white heat. 

By this agent, in conjunction with the ergot, I have recently, in the 
case of a carpenter presenting all the symptoms of acute partial myeli- 
tis involving the lower dorsal region of the cord, succeeded in effecting 
such a mitigation of the disease as to arrest its onward progress, and 
restore motion and sensibility to the paralyzed limbs to quite an ap- 
preciable extent. The ergot was administered in doses of a drachm 
every two hours for five days. Two cauterizations were made during 
this period. During the ensuing thirty days the ergot was given in 
similar doses three times daily, and two additional cauterizations were 
performed. The patient was then left without further medical interfer- 
ence, being able to move his legs, to pass and retain his urine, and to 
feel impressions made on the skin below the seat of the disease. While 
complete recovery will not probably result, I am quite satisfied that life 
was saved by the action of the agents in question. 

II. 

INFLAMMATION LIMITED TO THE ANTEEIOE TEACT OP GEAY MATTEE OP 

THE SPINAL COED. 

I have preferred to include the diseases next to be considered, 
under the title above given, in preference to others which have 
been brought forward. Thus the term " anterior horns of gray mat- 
ter" would not apply to the medulla oblongata, and that of "motor 
tract" employed by Dr. E. S. Seguin, 1 does not accord with the views 
I entertain relative to the physiological anatomy of the region referred 
to, it being, in my opinion, trophic as well as motor in function. The 
1 " Spinal Paralysis of the Adult," etc., New York, 1874. 



438 DISEASES OF THE SPINAL CORD. 

term " anterior tract of gray matter" is not only sufficiently precise 
as regards the spinal cord proper, but it can logically be applied to 
the corresponding mass of ganglionic tissue in the medulla oblongata, 
and at the same time does not commit us in advance to any views 
relative to the office of this gray matter as a nerve-centre. 

In inflammation limited to the anterior tract of gray matter of the 
spinal cord, including the medulla oblongata, the morbid process may 
involve both the motor and trophic cells — that is, all the nervous ele- 
ments of which the tissue is composed — or it may be restricted on 
the one part to the motor cells, and on the other to the trophic cells. 

There are, thus, three categories of diseases to be considered under 
the general head of inflammation limited to the Anterior Tract of Gray 
JMatter of the Spinal Cord, viz.: 

1. Inflammation of motor and trophic nerve-cells : a. Infantile 
spinal paralysis, b. Spinal paralysis of adults. 

2. Inflammation of the motor-cells : a. Glosso-labio-laryngeal pa- 
ralysis. 

3. Inflammation of the trophic cells : a. Progressive muscular 
atrophy, b. Progressive facial atrophy. 

In addition to these primary affections, there are others in which 
the anterior tract of gray matter is involved secondarily, or at least in 
conjunction with inflammation of the white substance, entering into 
the composition of the anterolateral columns of the cord. These will 
be considered under another head. 

1. Inflammation of Motor and Trophic Nerve- Cells. 

All the diseases of this class are characterized by two essential phe- 
nomena, paralysis and atrophy. The paralysis is the first of these symp- 
toms to make its appearance, the atrophy following more or less closely, 
and ensuing not as a consequence of paralysis and disuse, but as an active 
pathological condition. The chief reasons, as we shall see hereafter, for 
the theory of the existence of trophic cells in the spinal cord, are found 
in the facts that the atrophy is an independent feature of the diseases 
of the class under notice, and that it may exist without paralysis at 
all, except in so far as an atrophied muscle is necessarily weaker than 
one not so affected ; and, again, that paralysis may exist without atro- 
phy, and the gray matter of the anterior tract alone be involved. 

a. Infantile Spinal Paralysis — Organic Infantile Paralysis — 
Anterior Polio-myelitis. 

Under the name of organic infantile paralysis — to which term, now 
that the morbid anatomy is well understood, that of infantile spinal 
paralysis is to be preferred — I have considered at length * a form of 

1 Journal of Psychological Medicine, No. 1, 1867, p. 49. Also, my translation of 
Meyer's " Electricity in its Relations to Practical Medicine," New York, 1870, p. 228, note. 



INFANTILE SPINAL PARALYSIS. 439 

paralysis occurring in young children, previously described by Heine, 1 
who was the first to direct special attention to it under the name used 
at the head of this section ; by Rilliet 2 and Barthez as the paralysie 
esscntielle de Venfanee, and by Duchenne 8 as paralysie atrophique grais- 
seuse de Venfance. Previous to the writings of these authors, the affec- 
tion in question was not distinctly recognized as a separate disease, but 
was confounded with a much less serious disorder, probably belonging to 
the class already considered under the head of angemia of the anterior 
columns of the spinal cord. The tendency in the present affection to 
muscular atrophy, and the permanent character of the paralysis, are 
phenomena which sufficiently distinguish it from the temporary paraly- 
sis referred to. 

Symptoms. — The beginning of infantile spinal paralysis is generally 
indicated by febrile excitement, convulsions, and pain in the back. This 
pain marks the seat of the disease in the spinal cord to which the paraly- 
sis of the muscles is due. These symptoms last for a few days, or they 
may be so slight as in very young children not to attract attention; or, 
again, they may be absent altogether. 

Sometimes the paralysis is readily observed from the first, both by 
its extent and intensity; at others, it is not perceived till some one 
notices that the child does not use one hand or kick with one leg. The 
age of the patient, of course, exercises considerable influence on the 
question of ascertaining the existence of the paralysis at an early 
period. All four of the limbs may be affected, or the paralysis may be 
restricted to the legs, or more rarely to the arms, or to one arm and 
one leg of the same side, or of opposite sides, or to one leg or one arm, 
or even to a group of muscles or a single muscle. 

The temperature of the affected limbs is always much lower than 
that of the corresponding sound ones. The difference is sometimes as 
much as eight or ten degrees, though generally it is not more than five. 
If, spontaneously or under appropriate treatment, amendment takes 
place, the first indication is shown by the return of the temperature 
toward the natural standard. It thus becomes important to have some 
means by which a very slight increase of heat may be noticed. A deli- 
cate thermometer graduated to tenths of a degree will generally suffice, 
but much more exact indications may be obtained by Lombard's thermo- 
electric differential calorimeter, described in the introduction to this 
treatise. One of the thermo-electric piles is placed on the sound limb, 

1 " Beobachtungen iiber Lahmungszustande der untern Extremitaten und deren Be- 
handlung," Stuttgart, 1840 ; and " Spiuale Kinderlahmung," zweite Auflage, Stuttgart, 
1860. 

2 " Traite, clinique et pratique, des maladies de l'enfance," Paris, 1853, tome ji., 
p. 335. 

3 Gazette hebdomadaire, 1845, and " Traite de 1' electrisation localisee," l re edition, 
Paris, 1855. 



440 DISEASES OF THE SPINAL CORD. 

the other on the corresponding part of the paralyzed limb. Both are 
in connection, by delicate silk-covered wire, with the poles of a gal- 
vanometer. If the temperature of both limbs be the same, the needle 
of the galvanometer remains quiet. If either be warmer than the 
other, the needle is deflected to the north or the south, according as 
one or the other limb has the higher temperature. By this apparatus, 
very small fractions of a degree of temperature can be determined with 
absolute certainty. 

Sensibility is not materially, if at all, lessened, though the reflex 
excitability is diminished, and often entirely abolished, from the very 
first. 

The faradaic current almost always fails from the earliest period 
to cause contractions in the paralyzed muscles, but the galvanic cur- 
rent will, even when of low tension, produce movements in the most 
thoroughly paralyzed muscles, before the stage of atrophy is reached, 
but it will be observed that the anodal closure contraction equals, 
if it does not exceed, the cathodal closure contraction. This is a 
condition diametrically opposite to a normal state of the spinal cord 
and motor nerves (see page 29). As the atrophy advances, the 
muscles respond less and less to the galvanic current, and finally 
cease altogether. This first period of infantile spinal paralysis, in 
which the loss of power is the most obvious symptom, may last 
a month, or even six months, before the second period, character- 
ized by atrophy, begins. It is then usually the case that the paralysis 
gradually disappears to a great extent, if the loss of motor power 
has in the first place been extensive. Even when the paralysis has 
been restricted to a single limb, some muscles regain their function, 
and in either case complete restoration may occur. In those parts, 
however, in which there is no retrogression of the disease, atrophy 
ensues, and advances sometimes with great rapidity. The tempera- 
ture falls still lower, till, in some cases, it is scarcely higher than 
that of the surrounding atmosphere. In a patient from Maine, a 
little girl of about ten years of age, in whom both the lower ex- 
tremities remained paralyzed, and were atrophied to a very marked 
degree, the temperature of the legs below the knee was only 75° 
Fahr. in an atmosphere of 72°. The skin is of a livid hue, and 
pressure with the point of the finger causes a white spot to appear, 
which does not again become colored for some time, owing to the 
torpidity of the capillary circulation. 

With this atrophy, the electric contractility of the muscles disap- 
pears, although it has begun to be lost at an earlier period, and hence 
the strongest induced currents fail to cause the slightest contraction, 
and in some cases even powerful primary currents are equally ineffica- 
cious. Indeed, in no other disease is the electric excitability so thor- 
oughly abolished as in that under consideration. 



INFANTILE SPINAL PARALYSIS. 441 

Owing to the atrophy and consequent weakness of the muscles which 
surround the articulations, as well as to relaxation of the ligaments of 
the paralyzed limbs, the bones entering into the composition of the 
joints become separated. This condition is especially manifested when 
the upper extremity is the affected part, as regards the shoulder, the 
head of the humerus sometimes falling away from the glenoid cavity to 
the extent of an inch or more. The passive mobility of the joint is 
therefore very greatly increased, and dislocation is readily effected. 

If, as is often the case, certain muscles of a limb regain their power, 
while others remain paralyzed, the normal equilibrium is destroyed, and 
distortions of various kinds are consequently produced. Hence, infan- 
tile spinal paralysis is among the most important causes of club-feet. 

The bones are also subject to atrophy and to arrest of growth, and 
therefore the paralyzed and atrophied limb eventually is shorter than 
the corresponding sound member. In the case of a boy, six years old, 
who, several years since, was under my charge, the left arm, in conse- 
quence of infantile spinal paralysis occurring in his second year, was 
two inches shorter than the right. This arrest of growth was not very 
evident when the child was dressed, and the limb, by its own weight, 
hung by the side, for the reason that the head of the humerus was sep- 
arated nearly two inches from the glenoid cavity, but, when the bones 
were brought into apposition, the shortening was of course apparent. 
This extension of the atrophy and arrest of development to the os- 
seous system is by no means an invariable accompaniment, and is per- 
haps never produced unless the original central lesion is profound, and 
the muscles, generally, of an extremity are involved. 

Unless death should occur during the first stage of the disease, it is 
not probable that spinal infantile paralysis will in any case tend to 
shorten life. Tho tendency is for the spinal lesion to limit itself, and 
hence, when the second stage of the disease appears, there is no proba- 
bility that any extension of the morbid process will take place. The 
consequences are entirely restricted to the parts which are in nervous 
relation with the regioii of the cord in which the central lesion exists. 

At no time during the course of spinal infantile paralysis is either 
the bladder or its sphincter paralyzed, neither is the sphincter ani de- 
prived of its contractile power. 

The muscles most apt, according to my experience, to become the 
ultimate seat of the paralysis and atrophy are the tibialis anticus, the 
peroneal, the deltoid, the gluteal, the extensors of the toes, and the 
quadriceps femoris. I have never seen a case in which any muscle of 
the head or neck was involved. Seguin 1 states that the temporal has 
been found paralyzed once. Bed-sores or atrophic ulcerations of the skin 
rarely occur. I have never observed a case in which they were present 
— a fact which goes to show that, notwithstanding the appearance of the 
1 "Infantile Spinal Paralysis, 1 ' Medical Record, January 15, 1874. 



442 DISEASES OF THE SPINAL CORD. 

surface over the paralyzed parts, the nutrition of the skin is not essen- 
tially lessened. 

Causes. — Little is known of the etiology of infantile spinal paralysis. 
In two cases under my observation, occurring in brothers, it was ap- 
parently induced by the nurse allowing the infants to lie on the damp 
ground for an hour or more ; in several other cases, it came on while 
the children were suffering from teething, and in others it has followed 
diseases of various kinds, such as whooping-cough, measles, scarlet fever, 
etc. In the great majority of the cases that I have witnessed, no cause 
could be reasonably assigned. 

More than half of the cases occur during the first two years of life. 
M. Duchenne (de Boulogne), the younger, 1 of fifty-six cases occurring 
in the private practice of his father, finds the proportion of cases, for the 
several ages up to ten years, as follows : 

Twelve days after birth 1 

At the age of one month 1 

At two months 2 

At from four to six months 6 

At from six months to a year 6 

From one year to eighteen months 20 

From eighteen months to two years 11 

From two to three years 6 

From three to four years 2 

At seven years. . . , 1 

At ten years 1 

Total 56 

Diagnosis. — The symptoms of infantile spinal paralysis in the early 
part of its first stage are rarely so characteristic as to admit of a rational 
diagnosis being given. They are such as are met with in many other 
affections, and the early age of the patient is usually an obstacle to ex- 
act inquiries. I shall, under the head of morbid anatomy, cite cases in 
which spinal haemorrhage has produced symptoms in some respects simi- 
lar to those of infantile spinal paralysis, but such cases are extremely rare, 
and they are not characterized by the progressive atrophy and marked 
reduction of temperature so characteristic of the affection under notice. 
Setting them aside, it is not probable that, having in view the phenomena 
of the disease, the intelligent physician of the present day will blunder 
in his diagnosis. The absence of cerebral symptoms, the cessation of 
the fever when it has existed, and the general good health of the pa- 
tient, will go to render the diagnosis still more certain. The only con- 
dition with which the disease in question may be confounded, is the 
temporary paralysis due to reflex irritations, and probably the direct 

1 Duchenne (de Boulogne), " De l'electrisation localisee," troisieme Edition, Paris, 
1872, p. 417. 



INFANTILE SPINAL PARALYSIS. 443 

consequence of spinal anaemia. But the fact that such irritations are 
generally sufficiently evident, and that the paralysis disappears with 
their removal, will not permit us to remain long in doubt. As the dis- 
ease advances to its full development, the symptoms become more and 
more characteristic, until doubt is scarcely any longer possible. In fact, 
in its entirety, infantile spinal paralysis cannot be mistaken for any 
other affection. 

Prognosis. — Infantile spinal paralysis is not an affection liable to 
terminate fatally. Death may possibly occur in the very inception of 
the disorder from the irritation and general disturbance due to the in- 
flammation of the cord, but, though I admit the possibility of such an 
event, none such has ever come under my observation, nor have I been 
able to find any such recorded. The prognosis is therefore only of im- 
portance as regards the consequent paralysis and atrophy. And here 
it depends very much upon the fact as to whether the disease has ad- 
vanced so far as to have resulted in the abolition of the electric con- 
tractility of the affected muscles. If this is lost to the induced current, 
the cure will be difficult, and the treatment protracted ; if the primary 
current is also powerless, a cure is impossible. I believe I was the first 
to use the primary current in the treatment of infantile paralysis, and 
to insist on its great value as a curative agent, and as an element in the 
prognosis. 1 If the muscles can be made to contract with either the in- 
duced or primary currents, the cure is often merely a matter of time 
and patience. But regard must also be had to the extent of the pa- 
ralysis and atrophy. If all the muscles of one or more of the limbs are 
involved, and if contractions in the non-affected muscles have interfered 
to any considerable extent with the conformation of the joints, a cure 
will be next to 'impossible. While, therefore, recognizing the severity of 
the lesions in infantile spinal paralysis, and the tediousness of the meth- 
ods of cure, I cannot look upon the affection with the hopelessness of 
Volkmann. 3 For with Dr. Radcliffe 3 I am every day more and more 
convinced that muscles which I should once have looked upon as hope- 
lessly paralyzed, may be resuscitated by proper treatment. 

Again, it must not be forgotten that the most extensive paralysis, 
in the disease under consideration, may in great part, or entirely, spon- 
taneously disappear before the atrophy begins to make its appearance. 
It is not, therefore, safe to venture on a prediction as to the ultimate 
result at any time anterior to the stage of atrophy. 

Morbid Anatomy. — The morbid anatomy of infantile spinal paralysis 
is to be studied in the spinal cord, the nerves, the muscles, and the 
bones — the lesions in the three latter tissues being secondary to those 

1 New York Medical Journal, December, 1865. 

2 " Ueber Kinderlahmung und paralytische Contracturen-Sammlung," Klinische Vor- 
trage, No. 1, Leipzig, 18*70. 

1 Reynolds's " System of Medicine," vol iil, p. 666. 



444 DISEASES OF THE SPINAL CORD. 

existing in the cord. Previous to the recent investigations of Vul° 
piar and Prevost, Dr. Lockhart Clarke, and Charcot and his pupils, 
there was no approach to uniformity relative to the essential character 
cf the disease, many observers denying that there was any structural 
central lesion. Even since this last-named distinguished observer, in 
conjunction with Joffroy, published the report of his notable case, with 
a detailed statement of the post-mortem appearances, and since his 
results have been confirmed by others, we find so prominent a teacher 
and physician as Dr. West 1 ignoring them altogether, and concentrating 
his attention entirely on the eccentric lesions in a few brief sentences. 

It is not to be denied that paralysis of spinal origin may exist in 
children and be a very different affection from the one under notice. 
Paralysis, like cough, is only a symptom which may be due to many 
very different lesions. Thus, in a case of paralysis in a child six years 
of age, which had begun four years previously, and which involved the 
left lower extremity, I had the opportunity of making a post-mortem 
examination — death occurring from pneumonia. On examining the 
spinal cord, I found in the lower part of the dorsal region, and in the 
left anterior column, a cicatrix partially filled with a very small clot. 
No microscopical examination was made, and hence the condition of 
the anterior cornua was not ascertained. The atrophy of the paralyzed 
muscles was very slight, and it is therefore possible that there was no 
primary lesion of the nerve-cells of the anterior horns. The paralysis 
had ensued suddenly, and may have followed a fall or a blow — no ac- 
curate history could be obtained. I then, and for some time subse- 
quently, regarded this case as one of infantile spinal paralysis as at 
present understood, but I am now entirely satisfied that, beyond the 
loss of motor power, it had little in common with this affection. The 
slight atrophy which existed was possibly the result of secondary de- 
generation of a few cells of the left anterior horn, and not a conse- 
quence of any primary lesion of this region. A histological examination 
would have done much toward the elucidation of this interesting case, 
but it was at the time impossible. 

Dr. Clifford Allbutt 2 has reported a case in which the symptoms were 
more clearly the result of hemorrhage. The patient was an infant in 
good health, seven months old. One evening the mother lifted the 
child rather suddenly, and was astonished to see the body fall heavily 
forward. There were no evidences of pain, but she shortly afterward 
perceived that it was paralyzed in all four limbs. Death ensued in a 
short time from implication of the respiratory nerves. The spinal cord 
was submitted to careful examination, and two hemorrhagic clots were 
discovered in the cervical region. One of these, of small size, was in the 

1 " On some Disorders of the Nervous System in Childhood " — being the Lumleian 
Lectures for 1871, Philadelphia, 1871, p. 87. 

2 The Lancet, vol. ii., 1870, p. 84. 



INFANTILE SPINAL PARALYSIS. 445 

left posterior horn; the other, larger, was in the right posterior horn 
and lateral column. If these clots had been formed in the lower dorsal 
region the infant would probably have survived, and the case might 
have been regarded as one of infantile spinal paralysis. 

In a case reported by Hayem, 1 the patient was attacked with pa- 
ralysis of the lower extremities at the age of two years. Death took 
place twenty-two years afterward, of phthisis. The gray substance of 
the cord contained blood-pigment disseminated through its substance. 

Such instances, as I have said, only go to show the similarity of symp- 
toms which may result from very different causes, and like examples will 
readily occur to the reader as being afforded by unlike lesions in other 
parts of the body. 

The first attempt to associate spinal infantile paralysis with lesion 
of the anterior horns of the spinal cord was made by Cornil, 1 who re- 
ported the case of a patient affected with the disease in question, who 
died of cancer of the mammary gland at the age of forty-nine. The 
affection had been contracted by the subject, when an infant two years 
old, being left to lie for a long time on cold and damp ground. The 
muscles of the inferior extremities, especially those of the left, were 
paralyzed and atrophied. The post-mortem examination, which ex- 
tended to the muscles, the nerves, and the spinal cord, revealed the ex- 
istence in this latter organ of atrophy of the anterior horns of gray 
matter and of the ant ero -lateral columns — in those parts of the cord 
from which emanated the nerves going to the affected muscles. This 
case was the first published, in which lesion of the cord was noted in 
connection with infantile spinal paralysis, though the author states that 
he had previously, in 1863, observed an increased development of con- 
nective tissue in the anterior columns. The case of haemorrhage coming 
under my own notice, previously cited, occurred in 1858. 

Prevost a described, in 1865, the case of a woman, aged seventy-eight, 
in whom there was paralysis of the left leg, with deformation of the 
foot, evidently, in the opinion of M. Vulpian, whose patient she was 
in the Salp^triere, the result of infantile spinal paralysis. The muscles 
of the left leg and foot, as well as those of the lower part of the thigh, 
were much atrophied. The patient was demented, and died of phthisis. 
Post-mortem examination showed the left anterior horn of gray matter 
to be atrophied. On microscopical examination, it was seen that all 
the external part of this horn had undergone an alteration, the nerve- 
cells being replaced by a cellular and nuclear tissue evidently the pro 
liferation of the neuroglia. This was colored red by carmine. Amy- 
loid corpuscles were also present. The ganglion-cells of this part had 
almost entirely disappeared, and the one or two that remained were 

" Comptes rendus des seances, et memoires de la societe* de biologie," 1869, 18*70. 
2 Ibid., tome v., sene iii., 1863, p. 187. 



446 DISEASES OF THE SPINAL CORD. 

atrophied. The cells of the internal group were also diminished in 
number. The right anterior horn was normal. 

This was the first case in which atrophy and disappearance of the 
cells of the anterior horn were found associated with infantile spinal 
paralysis. 

In 1868, Dr. Lockhart Clarke, 1 in collaboration with Mr. Z. Johnson, 
published, under the head of muscular atrophy, the details of a case 
which was clearly one of infantile spinal paralysis. The disease had 
ensued in early infancy, immediately after inoculation with small-pox 
virus, and involved both upper ■ extremities, which, besides being para- 
lyzed, were greatly atrophied. Examination of the cord showed atrophy 
and softening of both anterior horns, with atrophy and degeneration of 
nerve-cells. In many places the cells had disappeared. 

Then in 1870, 2 Charcot, in conjunction with his pupil Joffroy, gave 
the results of his examination of a case which may be considered as defi- 
nitely settling the question of the morbid anatomy of infantile spinal 
paralysis. The patient, a woman named Wilson, died at the age of 
forty-five years, of phthisis, having been the subject of paralysis since 
childhood. The disease had suddenly made its appearance when she 
was seven years old, and had at first involved all four limbs. At the 
end of a year the upper extremities had in a measure regained their 
power, the lower remained atrophied and nearly altogether paralyzed. 

On post-mortem examination the spinal cord was found to be affected 
from the cervical to the lumbar enlargement. The alterations were 
chiefly in the gray matter, and especially in the anterior cornua. These 
were atrophied and distorted, and the cells had disappeared to a very 
great extent. In some places entire groups of cells had disappeared, 
without leaving any traces of their former presence. In the immediate 
vicinity of some of the points of cellular atrophy, the neuroglia had un- 
dergone sclerous transformation, but there were places where the lesion 
of the cells was the only alteration which could be discovered. 

Since the publication of the details of Charcot's case, several others 
have been reported, and a number of excellent monographs have been 
written in illustration of the morbid anatomy of infantile spinal paraly- 
sis. Among these may be cited those of Parrot and Joffroy, 3 Roger and 
Damaschino, 4 Dujardin-Beaumetz, 5 Petitfils, 6 Seguin, 7 Putnam- Jacobi, 8 

1 " On a Remarkable Case of Extreme Muscular Atrophy, with Extensive Disease of 
the Spinal Cord, 1 ' " Medico-Chirurgical Transactions," Second Series, vol. xxxiii., 1868, 
p. 249. 

2 " Archives de Physiologie," tome iii., 1870, p. 135. 

3 Ibid., 1870, p. 310. 

4 " Recherches anatomo-pathologiques sur la paralysie de l'enfance," Gazette Medicate 
de Paris, 1871, Nos. 41, 43, 45, 48, and 51. 5 " De la myelite aigue," Paris, 1872. 

6 "Considerations sur l'atrophie des cellules motrices," Paris, 1873. 
1 "Infantile Spinal Paralysis," Medical Record, January 15, 1874. 
8 American Journal of Obstetrics, May, 1874. 



INFANTILE SPINAL PARALYSIS. 
Fig. 34. 



447 




and Charcot, 1 who has quite recently traversed the whole ground, and 
who has admirably summed up what is known of the whole subject. 



Fig. 35. 




1 Revue photographique des hopitaux, Janvier et Fevrier, 1872, and "Lecons sur lati 
maladies du systeme nerveux," fascicule iii., Paris, 1874. 



448 



DISEASES OF THE SPINAL CORD. 



They all go to show that the essential lesion in infantile spinal paraly- 
sis is situated in the anterior horns of gray matter, and that it consists 
of a myelitis, in consequence of which there is an atrophy of the part 
affected, a degeneration of its structure, and a disappearance of its cell- 
elements. This contraction or atrophy is well shown in the accompa- 
nying woodcut from Charcot (Fig. 34), which represents a magnified 
section of the spinal cord taken from the cervical region of a woman, 
aged fifty years, who died in the Salpetriere, of general paralysis of the 
insane, and in whom there was infantile spinal paralysis affecting the 
right superior extremity. The atrophy of the right anterior horn is 
well marked, and the emaciation of the right antero-lateral and poste- 
rior columns, probably a secondary complication, is also notable. 

The atrophy and disappearance of the nerve-cells are sometimes ex- 
ceedingly limited. In the accompanying figure (Fig. 35), also from Char- 
cot, an enlarged view is given of a section of the spinal cord taken from 
the lumbar region in a case of infantile spinal paralysis, affecting the 
right lower extremity : A, the left anterior horn, healthy ; a, healthy 
group of ganglion-cells ; B, right anterior horn ; 5, median ganglionary 
nucleus, of which the cells are destroyed, and which is represented by a 
foyer of sclerosis. In Fig. 36 a still more enlarged view is given of the 




right anterior horn : a, cervix of the posterior horn ; 5, postero-external 
group of nerve-cells ; c, antero-external group, the cells of which have 
entirely disappeared, while they are intact in groups b and d ; d, inter- 
nal group ; e, the commissure. 

The myelitis is parenchymatous in character, that is, it begins in the 



INFANTILE SPINAL PARALYSIS. 



449 



nerve-cell structure, and, if the neuroglia be found involved, it is from 
the extension of the morbid process, and not from any primary implica- 
tion. This is sufficiently established, not only from an examination of 
sections of the cord, such as that represented in the last figure in which 
the lesion is restricted to the nervous elements, but from a consideration 
of the physiological relation which exists between the cells of the 
anterior horn and the functions which they have to perform — func- 
tions which are interfered with in cases of infantile spinal paralysis. 

Roger and Damaschino * have had the opportunity of making histo- 
logical examinations in three cases of infantile spinal paralysis, in which 
death took place from intercurrent affections while the disease was still 
in its early stage. As the result of their observations they conclude 
that — 

" 1. The characteristic alteration of infantile paralysis is a lesion 
of the spinal cord, of which the atrophy of the nerves and muscles is 
the consequence. 

"2. This lesion is more particularly seated in the anterior portion 
of the gray spinal substance, where it is seen in the form of centres of 
softening. 

" 3. This softening is of an inflammatory character, and the disease 
is a myelitis. 

"4. Infantile paralysis ought therefore to be called infantile spinal 
paralysis, and moreover its nosological position is certainly among the 
affections of the cord, and among the myelites." 

As regards the cell-alterations they found them to consist in atro- 
phy, with pigmentation. 

Charcot 2 has figured the changes which the cells of the anterior 
horns undergo in such cases : A represents the normal state ; JB, a cell 
hypertrophied ; C, pigmentary alteration of the last stage of pigmen- 
tary change ; JEJ y a cell in a state of sclerous atrophy ; and F, vacuolary 
alteration, which latter may be the result of the processes used in pre- 
paring the specimens — Fig. 37. » 

The anterior roots of the nerves coming from the affected region 
have been found atrophied, the myeline having disappeared, and only 
the axis-cylinder remaining. In other cases the nerve-tubules have been 
found to be very attenuated, and separated from each other by large 
spaces filled with connective tissue. 

The ganglia of the sympathetic have been examined by Roger and 
Damaschino, but exhibited no change from their normal structure. 

The bones of the paralyzed parts undergo atrophy with the muscles, 
though, when the lesion is not extensive, the bony atrophy may escape 
recognition. We have already seen that the affected extremities are 
often submitted to an arrest or retardation of growth. Besides this con- 

1 Op. cit. 

8 Leeons sur les maladies du systeme nerveux, troisi&me partie, Paris, 1874, p. 184. 
30 



450 DISEASES OF THE SPINAL CORD. 

dition, there is a cessation in the development of the bone laterally, and 
consequently its shaft remains smaller than is natural. The articular ex- 
tremities of the affected bones lose their cartilages, and are more or 

Fig. 37. 






I 



less arrested in their development. Examined microscopically, as has 
been done by Laborde * and others, the osseous tissue is found to present 
a deficient number of bone-cells and an excessive amount of medullary 
elements and adipose matter. It does not appear that the normal rela- 
tion of earthy to animal matter is disturbed to such an extent as to 
render the bones either especially liable to fracture or distortion. 

But, of all the peripheric lesions, those of the muscles have attracted 
the most attention, and have been the most carefully studied. It ap- 
pears to be settled without doubt that the first stage of atrophy is char- 
acterized by a diminution of the diameter of the muscular fibrillar, and 
that there is not then any histological evidence of a tendency to fatty 
degeneration. 

At this time there is an increased formation of connective tissue — 
a process which appears to persist for a considerable period. 

Eventually the atrophied muscles tend, in the great majority of 
cases, to break down into fat. The transverse strige disappear, and the 
degeneration, at first granular and bony, becomes unmistakably fatty. 
Eventually the muscle consists of nothing but fat and connective tissue, 
and in time the former disappears, leaving only a mass composed of the 
sarcolemmge and connective tissue. 

The nature of the morbid process is well shown in the accompanying 
woodcuts, made from my own drawings of the microscopical appear- 

lu De la paraiysie essentielle de Tenfance," These de Paris, 1864, p. 30. 



INFANTILE SPINAL PAEALYSIS. 



451 



ances of portions of diseased muscles removed by Duchenne's trocar. 
Fig. 38 represents a portion of the upper part of the tibialis anticus 
muscle of a boy who had suffered from organic infantile paralysis for 
over two years, and in whom the progress of the atrophy was exceed- 



Fig. 38. 




ingly rapid. Oil-globules are seen along the course of the fibrill^e. 
These latter are irregular and torn, and the transverse strise are becom- 
ing dim. 

In Fig. 39 a still more advanced stage is shown. This cut repre- 



FlG. 



H=* 



sents a portion of the same muscle taken from the lower part. The 
transverse strias have nearly disappeared, oil-globules are seen in large 
numbers, and fat-corpuscles are also abundant. 

In Fig. 40 the progress of the disease is well shown. The upper 



Fig. 40. 




margin of the specimen is a mass of fat-globules, and throughout the 
whole the transverse stride are absent. 

In Fig. 41 is shown a portion taken from the same muscle one monoh 
after the preceding specimens were removed. The transverse striae are 
entirely gone, and the muscle is a mass of oil-globules and fat-vesi- 
cles. 



452 



DISEASES OF THE SPINAL CORD. 

Fro. 41. 




Fig. 42 represents a piece of the same muscle six weeks later. It 
is now nothing more than a mass of connective tissue, the fat being 
almost entirely absorbed ; no transverse or longitudinal striae are to be 
perceived. 



Fig. 42. 




But there is not, as Duchenne affirms, this degeneration in every 
case of organic infantile paralysis. In two cases, which had lasted over 
four years, I found the structure of the muscle unchanged. There were 
atrophy, loss of electric contractility, and reduction of temperature, but 
every specimen of the affected muscles that I examined showed no 
change from the normal character. In every other respect the symp- 
toms were similar to those observed in ordinary cases of the disease. 
Improvement was very slow, but finally every muscle except the rectus 
femoris in one, and the tibialis anticus in the other, recovered, and the 
children were enabled to walk. The affection in both cases was con- 
fined to the left lower extremity. 

I am hence led to the conclusion that fatty degeneration of muscles, 
though the ordinary result of organic infantile paralysis, is not an inva- 
riable consequence. 1 

Pathology. — Whether all the cells of the anterior horns of gray 
matter are motor, or whether there are both motor and trophic cells, 
are questions which the histological examination of the normal struct- 

1 Journal of Psychological Medicine, No. 1, 1867, p. 57. Since the observations then 
published, other observers have arrived at the same conclusion. Thus, M. Charcot {Op. 
ctt., p. 161) says: "The surcharge of fat, although habitual in old cases of infantile mus- 
cular atrophy, is nevertheless not necessary. By the side of the muscles distended with 
fat, there are often others which are reduced to a very small volume, and in which the 
adipose tissue is almost entirely absent. In these last are found primitive fasciculi of 
very small diameter, but possessing their characteristic striation." 



INFANTILE SPINAL PARALYSIS. 453 

tire seems to be quite incapable of satisfactorily answering. Samuel ' 
has contended for the existence of a distinct system of nerves, the 
function of which is to preside over the nutrition of the parts to which 
they are distributed, and there is not wanting physiological evidence to 
support his theory ; as, for instance, the troubles of nutrition which 
result in the eye when the fifth pair is divided, and which Vulpian 9 
admits are due neither to irritation of the divided nerve-fibres nor to 
paralysis of the vaso-motor fibres contained in the nerve. Waller a has 
also expressed his opinion relative to the existence of distinct trophic 
centres in the cord. He regarded the ganglion of the posterior root as 
the trophic centre for this root, while che gray substance of the an- 
terior horns is the trophic centre for the anterior root. In regard to 
this theory, Weir Mitchell * expresses the opinion that it is still a matter 
of doubt, in which view all will unite till actual demonstration settles it 
affirmatively or negatively. 

But pathology points still more clearly than does physiology to the 
existence of trophic cells in the spinal cord. In infantile spinal pa- 
ralysis the peripheric disturbance is, in the first place, solely one of 
motility ; there is paralysis without atrophy. After a time, which 
may be as much as six months, or even more, the trophic changes be- 
gin. These, as we have seen, are not of that mild character resulting 
from disuse, but are active and intense, leading to the certain destruc- 
tion of whole groups of muscles, and even to arrest of development and 
degeneration of the bones. It is impossible, it appears to me, to ac- 
count satisfactorily for this atrophic process on the supposition that all 
the cells of the anterior horns of gray matter are motor, and that they 
alone are involved in the lesion. Charcot, however, constantly speaks 
of the affection in question as essentially consisting in an atrophy and 
disappearance of motor nerve-cells, and the majority of French writers 
adopt his view. Indeed, he argues very strenuously against the exist- 
ence of spinal trophic cells, in which, it appears to me, he ignores some 
of the most valuable contributions which he and others of his country- 
men have made to the pathology of the nervous system. A very impor- 
tant memoir of MM. Duchenne and Joffroy 6 throws much light upon this 
interesting subject, and will be fully considered under the head of pro- 
gressive muscular atrophy, when additional evidence in support of the 
theory of the existence of trophic cells will be adduced. 

But, whether we admit the existence of trophic cells in the anterior 
horns of gray matter or not, there is no doubt of the dependence of the 

1 "Die tropischen Nerven," Leipzig, 1860. 

3 " Lecons sur l'appareil vaso-moteur," Paris, 1875, tome ii., p. 377. 

3 " Proceedings of the Royal Society of London," vol. ii., 1860-'62. 

4 "Injuries of Nerves and their Consequences," Philadelphia, 1872, p. 78. 

6 " De l'atrophie aigue et chronique des cellules nerveuses," etc., Archives de physi- 
ologie, No. 4, 1870, p. 499. 



454 DISEASES OF THE SPINAL CORD. 

peripheric troubles on the central lesion. Some authors have assumed 
that the essential feature of the disease was some disturbance in the 
sympathetic nervous system; but there is no evidence to support this 
view. On the contrary, examination has shown that there is no appre- 
ciable lesion of this system, and the fact that all the functions of the 
organism are generally well performed in cases of infantile spinal pa- 
ralysis militates strongly against the hypothesis. 

No examination of the cord of a patient dying during the very ear- 
liest stage of infantile spinal paralysis has yet been made. Judging, 
however, from the character of the symptoms, and from their diffusion, 
and subsequent retrogression, it is extremely probable that, as in other 
inflammatory affections, there is congestion, and that this condition is 
not limited to the anterior tract of gray matter. As we have seen, 
pains not only in the cord, but in the limbs, are occasionally met with, 
and Vulpian ' refers to an instance in which there was complete anaes- 
thesia. In the case of a little girl whom he examined a few days after 
the invasion of the disease, and in whom the electro -muscular contrac- 
tility of the muscles of both inferior extremities was entirely abol- 
ished to strong f aradaic currents, sensibility was equally annihilated, 
so that the electric brush could be passed over the skin without pain 
being produced. 

The pathology of the deformations so generally met with in cases 
of infantile spinal paralysis is very obviously the result of the destruc- 
tion or impairment of that normal equilibrium which exists between the 
muscles. Thus, if the extensors of the hand are affected while the 
flexors remain unparalyzed, these latter will in time cause a flexion of 
the hand upon the forearm ; if the muscles of one side only of the spine 
are paralyzed, the muscles of the other side will produce a lateral curva- 
ture; if the extensors of the foot are alone deprived of their power, the 
strong gastrocnemius and soleus cause a talipes equinus; while, if these 
latter are the seat of the derangement while the extensors are healthy, 
a talipes calcaneus is the result ; and these conditions are more or less 
modified according as other muscles are more or less involved. 

Treatment. — The fact that infantile spinal paralysis is due to an 
organic affection of the spinal cord is no bar to treatment addressed to 
the peripheric lesions — it having been very definitely shown by numer- 
ous investigations that the integrity of nerve-centres is affected either 
favorably or unfavorably by eccentric nerve-conditions. It is therefore 
perfectly practicable, in favorable cases of the disease in question, so to 
improve the nutrition of the cord, by proper measures directed to the 
relief of the peripheric trouble, as to arrest the morbid process in the 
cells of the anterior horns, and even to effect their regeneration. The 
fact that cases of long-standing infantile spinal paralysis are cured — ■ 
cases in which there can be no doubt of the existence of the spinal 
1 " Lemons sur l'appareil raso-moteur," Paris, 1875, tome ii., p. 410. 



INFANTILE SPINAL PARALYSIS. 455 

lesion — is of itself sufficient evidence to establish the correctness of the 
view advanced. The investigations of MM. Masius and Van Lair, 1 
relative to the regeneration of the spinal cord, also show how great is 
the reparative power of the organ. They divided the cord in frogs, 
and at the end of from two to four months obtained indubitable evi- 
dence that the animals had regained voluntary movements and sensi- 
bility in the posterior extremities. In other frogs, histological exami- 
nation showed the more or less complete regeneration of the cord. 
The conditions which lead us to expect a favorable or an unfavorable 
result from treatment are stated under the head of prognosis. 

The treatment of the disease, however, consists both in the use of 
general and local means. Of the former, ergot is chief, and should be 
given as soon as we can determine the nature of the disease under 
which the child is suffering. Young children bear this remedy well. 
Infants of six months may take as much as ten drops of the fluid-ex- 
tract three times a day, and this may be increased to half a drachm for 
children of from one to two years. It is rarely the case, however, 
that w r e have the opportunity of giving this valuable agent from the 
very inception of the disease. But even after the first or febrile stage 
has subsided, when the affection is solely manifested by paralysis, be- 
fore the atrophic stage has begun, ergot is of great service — not to be 
surpassed, in my opinion, by any other medicine, and the only one 
capable of cutting short the disease, or lessening its extent. 

After the stage of atrophy is reached there is no longer any benefit 
to be derived from ergot ; strychnia is then useful because it is ca- 
pable of acting as a general stimulant to the nervous system, is pos- 
sessed of undoubted value in cases of degeneration of nervous tissue, 
and is, moreover, a tonic to the muscles. I generally prescribe it in 
union w 7 ith iron and phosphoric acid, according to the following form- 
ula: IJ. Strychnire sul. gr. j, ferri pyrophosph. 3 ss., acidi phosphorici 
I ss., syrupus zingiberis 3 iijss. M. ft. mist. Dose, a teaspoonful or 
less, according to the age of the patient. A child of from three to 
five years of age can take half a teaspoonful of this mixture thrice 
daily; or, the strychnia may be given advantageously in the form 
of hypodermic injections in doses suitable to the age. In children 
under one year old, the ninety-sixth of a grain is as much as should 
be given at a dose, and under six months it should not be administered 
at all. I am quite sure that strychnia, hypodermically introduced in 
very gradually-increased doses, is more efficacious than when taken 
into the stomach. 

The immediately local means of treatment are those which are cal- 
culated to promote the nutrition of the muscles, and restore or augment 
their contractile power. The first end is effected by causing a greater 

1 " Reckerches experimentales sur la regeneration anatomique et functionnelle de u» 
moelle epiniere," analyzed in Archives de Physiologie^ tome iv., p. 268. 



45 G DISEASES OF THE SPINAL CORD. 

amount of blood to flow through the diseased parts; the second is best 
accomplished by the persistent use of electricity, and active and passive 
exercise. 

Under the first head are embraced heat, friction, and kneading. 

Heat is best applied by means of hot water. A temperature of 
from 110° to 120° Fahr. may be used, and the limb should be thor- 
oughly immersed, and allowed to remain so for half an hour ; salt 
may be added to the water, with the view of augmenting the stimulant 
effect. 

Frictions with a dry towel, a flesh-brush, or the hand, are also ex- 
ceedingly useful; they should be practised several times in the course 
of the day, to the extent of reddening the skin. 

Kneading the muscles affords a means of exercising them, and of in- 
creasing the amount of blood in the vessels. They should be pinched 
firmly between the fingers of both hands to the extent of producing 
some little pain; every paralyzed muscle should be gone over in this 
way daily. 

Jeunod's boot, when the inferior extremity is the one affected, or a 
similar apparatus for the upper extremity, is an efficacious means of 
causing an increased flow of blood to the parts, and of producing a per- 
manent enlargement of the vessels. Care, however, should be taken 
that the exhaustion of the air be not carried too far. 

Under the second head, electricity comes first. If the induced cur- 
rent will produce contractions in the affected muscles, it should be em- 
ployed; but if, as often happens, it should fail to do so, the primary 
current interrupted must be brought into service. In the communica- 
tion 1 already cited, I called attention to this valuable agent in the 
treatment of organic infantile paralysis, and adduced several cases in 
illustration of its beneficial action. If a contraction can be induced by 
it, recovery is merely a matter of time, so far as that particular muscle 
is concerned. As soon as the muscle is so far developed as to contract 
to the induced current, this latter should be employed. Every alter- 
nate day is often enough for a sitting. The time necessary for each is, 
of course, dependent on the extent of the paralysis. 

During the period from December, 1865, to December, 1870, I 
treated ninety-eight cases of organic infantile paralysis. Of these, the 
disease was so far advanced in eleven as to render it very evident, after 
thorough examination, that success was out of the question. In the 
remaining eighty-seven, no contractions could be caused in the affected 
muscles by the strongest induced currents in thirty -nine; while in all 
of these the primary current produced decided contractions. Of the 
eighty-seven cases, fourteen were entirely cured; twenty-eight were 
greatly improved; thirty slightly improved, and the remainder — fifteen 
— discontinued treatment before sufficient time had elapsed to ascertain 
1 New York Medical Journal % December, 1865. 



INFANTILE SPINAL PARALYSIS. 457 

the effect. Since then I have kept no very full record of my cases, but 
I am enabled to state that the proportions do not vary essentially from 
those above stated. 

At the best, however, the treatment must be of long duration, and 
even when the muscles are entirely restored they must be reeducated 
to the performance of their functions. Few parents, comparatively, 
have the patience to wait and to devote the necessary time to doing 
their part of the work; unless there is a reasonable assurance in regard 
to these points, it is better not to undertake the case. It is not, except 
in recent cases, a matter of days, or of weeks, but of months, and some- 
times of years. 

But, even when fatfcy degeneration is going on, the disease may be 
arrested by the proper use of the direct current. Fig. 43 shows the ap- 
pearance of a portion of muscle as examined by the microscope, October 

Fig. 43. 




21, 1866. This specimen was removed from the belly of the gastro- 
cnemius muscle before any treatment whatever had been employed, and 
after the disease had existed, with gradually-advancing atrophy, for 
about four and a half months. 

Fig. 44 represents a piece of the same muscle from the same part, 
on December 3d, six weeks after the treatment was begun. In the 
first, oil-globules are seen to have displaced the muscular tissue to a 



f 



Fig. 44. 




great extent; the transverse strias have disappeared entirely from some 
parts, and are faintly seen even where they are present. In the second, 
the quantity of fat is perceived to be very much lessened, and the striae 
are much more numerous and distinct. This case, which was one of pa- 
ralysis of the left leg and foot, entirely recovered. 

I feel that I cannot insist too strongly on the use of the primary or 
galvanic current, when contractions cannot be obtained by the faradaic 



458 DISEASES OF THE SPINAL CORD. 

or induced current. If the electric contractility of the muscles is not 
utterly destroyed — as Dr. Radcliffe ' remarks — there appears to be no 
limit to the prospect of recovery. 

Whichever form of current be employed, it must be applied directly 
to the skin over the affected muscles, or, in some cases, to the nerves 
which go to them; and the current should be as strong as is necessary 
to cause contractions. Applying it through the hand of the physician 
is worse than useless. 

Along with the electricity, passive motions of the joints should be 
made, and the child should be encouraged to direct the will to the 
affected muscles as often and as powerfully as possible. 

A very valuable aid to the treatment, in cases of deformities, is af- 
forded by the use of apparatus calculated to take the tension from the 
paralyzed muscles. An overstretched muscle is in the worst possible 
state to react to the electrical stimulus, for the strain is of itself a most 
efficient agent in destroying its contractility. India-rubber cords may 
be very advantageously employed in this connection. 

As to tenotomy, the question of its propriety must be determined 
by the circumstances of each individual case, and may be left to the 
good sense of a competent orthopaedic surgeon. 

b. Spinal Paralysis of Adults, 

Duchenne, 2 to whom we owe the identification of several other 
affections of the nervous system, was the first to insist upon the fact 
that there was a form of paralysis met with in adults which presented 
great analogies with infantile spinal paralysis. He recognized two 
forms of this disorder, one he designated acute anterior spinal paralysis 
of adults, the other subacute general anterior spinal paralysis of 
adults. As these have the same patho-anatomical features and differ 
in their symptoms only as regards a few not very material points, there 
is nothing to be gained by considering them separately. 

In the third and last edition of his great work, 3 under the . head of 
spinal paralysis in the adult, he sums up his earlier and more recent 
investigations on the subject. 

But, though Duchenne has shown by the cases recorded in the first 
edition of his work published in 1855, and the remarks therein made 
in regard to them, that he was acquainted with a form of spinal paral- 
ysis occurring in adults characterized by loss of voluntary power, 

1 Article " Infantile Paralysis." Reynolds's " System of Medicine," vol. ii. 

2 As these pages are passing through the press, the death of this distinguished phy- 
sician is announced. Probably no one man has done so much as he for the advancement 
of neuropathology and therapeutics. The keenness of his observation was only equaled 
by his indomitable spirit of investigation and immense capacity for work. Iu him scien- 
tific medicine has lost a follower whose place will not soon be filled. 

* "De relectrisation localisee," Paris, 1872, p. 437. 



SPINAL PARALYSIS OF ADULTS. 459 

atrophy, and diminished electric contractility in the muscles, " as when 
the anterior columns of the cord are altered," Meyer, 1 of Berlin, is 
entitled to the credit of being the first clearly to state in a publication 
his belief in the existence of an affection holding intimate relations with 
infantile paralysis and to employ the term spinal paralysis of adults. 
Thus, after describing the first named disease he says : 

" A similar paralysis of the lower extremities occurs also in adults, 
occasioned by the existence of some exanthematous action or other 
unknown cause. The disease in such cases is of course subject to such 
modifications as the completed structure of the body would induce. 
Among these are the following : 1. As the bones of the adult are fully 
developed, that retardation in the structural growth of the affected 
members, which may occur in cases of infantile spinal paralysis, has 
here of course no place. 2. In consequence of the adult's greater energy 
of will impelling him to bring into action muscles which can be made to 
perform the duties of the paralyzed ones, as well as in consequence of 
the greater firmness and resisting power of the ligaments of the adult, 
secondary deformities are not developed to the same extent as in the 
spinal paralysis of children. 3. As in no case, so far as my observation 
goes, is the power of locomotion removed, there cannot be so great a 
disturbance in the circulation of the blood, nor, consequently, so 
remarkable a reduction of temperature. 4. On the other hand, as a 
result of the double amount of work devolved upon the muscles that 
perform the duties of the paralyzed ones, a striking hypertrophy of 
these muscles is induced. 

"Among other cases the following have fallen under my observation: 
"The two Barons von H., twin brothers, well-built, fine large men, 
uniformly healthy, in their eighteenth year, simultaneously fell sick 
with the measles. These having run an apparently favorable course, 
were followed in both with a paralysis of the legs inducing a constantly 
increasing emaciation of those parts. When I visited them, which was 
not till they had reached their twenty-fourth year, the circumference 
of the thighs of each measured respectively twenty and twenty-one 
inches, the circumference of the calves ten and ten and a half inches ; 
the latter dimension, if the normal relation of the thighs to the calves 
be as three to two, was accordingly four inches below the true stand- 
ard. The glutei muscles, on the contrary, as the patients made all loco- 
motory movements from the hip-joint, were developed to colossal 
proportions, contrasting strongly with the emaciated legs. Their walk 
was, therefore, very peculiar. As the legs could only be used as stilts, 
at every step of the right or left foot there occurred a rotary movement 
from behind forward of the right or left thigh, which communicated 

1 "Die Electricitat in ihrer Anwendung," etc., Berlin, 1868. See also my translation 
of this work, "Electricity in its Relations to Practical Medicine," second American 
edition, New York, 1874, p. 229. 



460 „ DISEASES OF THE SPINAL CORD. 

itself to the whole body, causing it to turn at every step toward the 
one or the other side. The extensor power of the leg was very limited; 
the dorsal extension of the foot and the flexion of the toes were not in 
the power of the patients, and but a slight adduction of the toes was 
possible; the patients trod upon the outer borders of the feet, and in 
the mm. tibiales, consequently, contorted forms were exhibited. The 
adductors of the thigh as well as the muscles of the foot were normally 
developed; on the other hand, the extensors of the knee-joint and all 
the muscles of the leg had suffered greatly in assimilative power. The 
sensibility of the skin and muscles was perfectly preserved. The 
electro-muscular contractility was reduced in the quadriceps femoris, 
and altogether wanting in the mm. peronei, the extensors digit, com., 
the gastrocnemii, etc.; but the adductors of the knee-joint and the 
toes showed a weak reaction." 

It is, therefore, quite apparent that Meyer had a very distinct con- 
ception of the disease in question. 

Since then a number of cases have been reported under different 
names, which are clearly instances of the affection in question, and no 
small amount of confusion exists in regard to the whole subject, from 
the fact that unnecessary refinement has been shown in classifying 
them. Thus, as we have seen, Duchenne describes two varieties — an 
acute anterior spinal paralysis of the adult and subacute general 
anterior spinal paralysis of adults. This latter has, by others, been 
designated acute ascending paralysis. After a full survey of the sub- 
ject and careful study of several cases of each, I am very decidedly of 
the opinion that these two varieties do not essentially differ from each 
other. The affection called by Duchenne l subacute diffused general 
spinal paralysis — a name calculated to add greatly to the already 
existing confusion — is evidently acute general myelitis. This view rela- 
tive to the identity of the two morbid states I have taught for two 
years past to the medical classes at the University of New York. It is 
sustained by very cogent reasoning by M. Petitfils, 2 and is held also 
with some reservation by Dr. E. S. Seguin 3 in his excellent little mono- 
graph on the affection in question. 

Symptoms. — The onset of the disease is generally sudden, and is 
usually characterized by pains in the back, which radiate to the limbs, 
and by the various sensations of numbness, especially in the extreme 
peripheric parts of the body. There may or may not be fever, and 
when it is present it is not ordinarily excessive. At the same time 
there is loss of the power of motion, varying in character and degree 
from the sudden and complete paralysis of all the limbs, to the gradual 

1 "L' electrisation localisee," troisieme edition, Paris, 1872. 
9 " Considerations sur l'atrophie aigue des cellules motrices," Paris, 1873, p. 83. 
3 " Spinal Paralysis of the Adult : Acute, Subacute, and Chronic — (Inflammation of 
the Motor Tract of the Spinal Cord"), New York. 1874. 



SPINAL PARALYSIS OF ADULTS. 461 

extension of the akinesis from a part of an extremity to one or more. 
At this early period, as I have recently had an opportunity of deter- 
mining, by means of Dr. Lombard's instrument for measuring differ- 
ences of temperature, there is an increase of heat in the affected ex- 
tremities amounting to from 2° to 4° Fahr. From the very first and 
throughout the whole course of the disease the sensibility ordinarily 
remains intact, and the pains which are commonly phenomena of the 
initial part of the primary stage disappear within the first two or 
three days, or even earlier, and sometimes are not present at all. 

The bladder and the sphincter ani generally remain unaffected. 
There are usually no cramps or spasmodic contractions of any of the 
muscles. Neither is any feeling of constriction experienced around the 
body. The electric contractility of the muscles is impaired at a very 
early stage, and generally goes on diminishing till at last very strong 
induced currents fail to cause any reaction. It is rare, however, that 
the excitability to the galvanic current is entirely abolished, except in 
long-continued and neglected cases, and, even in these, currents of great 
intensity will often cause contractions, but the reactions of degenera- 
tion are well marked. At the same time the cutaneous sensibility to 
all kinds of electrical stimulation remains unimpaired. 

Retiex contractions in all the paralyzed parts are difficult, and some- 
times impossible to excite from the very beginning. 

The face is rarely involved. In one of my own cases, however, one 
side was completely paralyzed, so far as the seventh pair of nerves was 
concerned, and Dr. Seguin 1 has reported an instance in which the 
third and facial nerves were both affected. Some of the other symp- 
toms go to show that this was not an uncomplicated case, and Dr. 
Seguin's diagnosis was " myelitis or degeneration of the anterior horns 
of gray matter of the cord ; the motor part being involved from the 
third cerebral nerve downward, w T ith probably recent extension of 
myelitis to deeper parts of cord at some points." 

In the majority of cases the paralyzed parts, after a period vary- 
ing from two or three weeks to several months, begin to recover their 
power, but it usually happens that the loss of motility remains in some 
muscles as in the infantile form of the disease. Atrophy may occur 
before the retrocession of the paralysis. Generally, however, its ap- 
pearance is first seen in those parts which remain paralyzed, and occa- 
sionally it is absent altogether. In all the cases collected and observed 
by Seguin, it was a prominent feature ; it was wanting in one of my 
own cases, that above referred to ; as it was likewise in a very inter- 
esting instance reported by Dr. Labadie-Lagrave, 2 in which the mus- 
cles of respiration were involved, but yet in which recovery took placj. 

i Op. cit., Case XXL, p. 19. 

2 " Observation de paralysie ascendante aigue." Brochure, extrait de la Gazette des 
Hopitaux, 18*70. 



462 DISEASES OF TIIE SPINAL CORD. 

The reduction of temperature, though marked, never, in my ex« 
perience, reaches the low point observed in the infantile form. The 
atrophy likewise is rarely so profound. But in the case of a gentleman 
of New Jersey, in whom the paralysis began slowly in the left lower 
extremity and gradually extended upward till the medulla oblongata 
was involved, and death produced from asphyxia, the wasting was rapid 
and extensive, till at last apparently nothing of the muscular tissue re- 
mained in the limb first affected. In this case the right side continued 
free from the least sign of paralysis so long as the patient was under 
my observation. 

In some cases which have been observed, the paralysis is first mani- 
fested in the lower limbs, and progressively advances upward till the 
superior extremities are affected. Still, in some cases continuing its 
progress, the medulla oblongata is reached, and death takes place by 
asphyxia. Or it may follow a descending course, the superior extremi- 
ties being first attacked, and subsequently the inferior. 

The muscles in some of these instances are very rapidly and pro- 
foundly atrophied, and can be seen to waste from day to day in groups. 

Such cases may be regarded as representing the subacute form as 
described by Duchenne. 

Other examples designated by the names of acute progressive pa- 
ralysis, acute ascending paralysis? etc., are in reality like those de- 
scribed by Duchenne under the title of subacute general diffused spinal 
paralysis, and are cases of general myelitis. Of such notably is the 
instance reported by Harley, 2 in which the post-mortem examination 
was made by Lockhart Clarke, and the lesion found to implicate not 
only the anterior horns but the posterior, and the antero-lateral and 
posterior columns. 

In no case that has been reported or that has come under my own 
notice was there any tendency exhibited to the formation of bed-sores. 

From the foregoing account it will be seen that the more prominent 
phenomena observed in cases of spinal paralysis in the adult are strik- 
ingly like those which characterize the infantile form. Even as regards 
the results there is no essential variation, except that due to difference 
of age. There is, of course, in the adult no arrest of development, and 
the disposition to deformities is not so great as in the infant, but nev- 
ertheless, as in the first case reported by Charcot, 3 they may occur. 

Occasionally, hyperesthesia exists. This was the case in two of 
Seguin's cases 4 — XX. and XXII. — and to a marked degree in that of 
Labadie-Lagrave. 6 Thus, as the latter remarks : 

1 Landry, "Note sur la paralysie ascendante aigue," Gazette Kebdomadaire, 1S50, pp. 
470, et seq. 

3 Lancet, October 3, 1868. 

3 "Lecons sur les maladies du systeme nerveux," fas. iii., 1874, p. 173. 

4 Op. cit, pp. 17, 22. 6 Op. cit, p. 6. 



SPINAL PARALYSIS OF ADULTS. 4G3 

"Besides the cutaneous hyperesthesia, there was a still more de- 
cided muscular hyperesthesia. The lightest pressure on the muscles 
was very painful, and caused the patient to cry out. In addition, lan- 
cinating pains were felt in the lumbar region, when the flexed thighs 
were suddenly extended. Passive movements of the lower extremities 
also caused a certain amount of pain." 

It is very certain that many cases of spinal paralysis and atrophy 
occurring previously to the last two or three years, and reported under 
other designations, were in fact instances of spinal paralysis of adults. 
This is probably true, for instance, as regards the " case of acute mus- 
cular atrophy," 1 occurring in the London Hospital in the service of Dr. 
Ramskill, relative to which it is stated that " electro-motility was ab- 
sent," a circumstance not present in progressive muscular atrophy. 

A case which forms the subject of a clinical lecture by Jaccoud 2 is 
clearly one of inflammation of the anterior tract of gray matter. The 
patient, a man seventy years of age, was seized with pains and numb- 
ness in the extremities, with incoordination. Shortly afterward there 
was loss of power in all four limbs, which progressively increased till at 
last he was unable to walk or to use his arms. At the same time atro- 
phy began in the paralyzed parts. Reflex movements were abolished 
and reflex excitability was either lost or impaired, in the affected mus- 
cles. There were pains and some loss of sensibility. Death ensued : 
on post-mortem examination the spinal arachnoid was found studded 
with fibrous plates, which pressed upon the roots of the nerves, causing 
their atrophy. Hence the name of progressive nervous atrophy which 
Jaccoud gives to the case. The spinal cord was pronounced healthy, 
but, as no microscopical examination was made of it, the opportunity 
was lost for discovering the real and essential lesion, the disease of the 
anterior horns, which undoubtedly existed. 

Some of the cases which I have, previous to the recognition of the 
affection under notice, regarded as instances of spinal congestion, pro- 
gressive muscular atrophy, and antero-lateral spinal sclerosis, were, I 
have now no doubt, examples of inflammation of the anterior tract of 
gray matter. Several of these I have reported. 

Among them is the case of Rose Peyton, who formed the subject of 
a clinical lecture I delivered at the Bellevue Hospital Medical College 3 
in the autumn of 1870, and of which my clinical assistant, Dr. Cross, 
prepared at the time the following report : " Rose Peyton, twenty-seven 
years of age, born in Ireland, mother of two children, both of whom are 

1 Quoted from the Larwet in the Quarterly Journal of Psychological Medicine, vol. iii., 
1869, p. 198. 

8 " De 1'atrophie nerveuse progressive," " Lecons de clinique medicale," second ecli» 
tion, Paris, 1869, p. 372. 

8 "Clinical Lectures on Diseases of the Nervous System," Quarterly Journal of Psy- 
chological Medicine, January, 1871, p. 22. 



464 DISEASES OF THE SPINAL CORD. 

living; the older has talipes valgus, while the younger is a fine, hearty 
child. Her family is very healthy, and there is no evidence of nervous 
diseases either in it or in any of its branches, so far as she is aware. 
The patient was a strong, active woman, and always did her own work 
until twelve weeks ago. In May there was a cessation of menstruation, 
and in July last she was seized with a deep, dull, aching pain in both 
legs, and which appeared to her to be in the bones. There is no syphi- 
litic taint in her history. There succeeded, shortly after, a severe pain 
in the back, which has continued up to the present time, but which has 
varied in intensity. Soon, loss of motility, numbness, and anaesthesia, 
made their appearance in both legs, and in the course of two months 
she was totally unable to walk. At first, her bowels were very costive, 
but soon this condition was succeeded by incontinence of the rectum, 
which lasted for two weeks, varying in degree. There was also reten- 
tion of urine. Sensations of formication alternating with numbness, 
of heat and cold, of pricking by pins and needles, were present not only 
in the feet and toes, but also in the hands and fingers. Patient noticed 
that on rising in the morning, after a night's rest, her limbs were 
weaker, and that she had greater difficulty in moving about. The 
paralysis, after commencing in the lower extremities, rapidly extended 
to the upper. August 25th. — Was able to get out of bed for the first 
time in five weeks, and by means of a chair could move about a very 
little. Since then she had improved only so much as to be able to come 
to the out-door department of the New York State Hospital for Dis- 
eases of the Nervous System, by being supported by a person on each 
side, and only then with extreme difficulty. She was admitted Septem- 
ber 22, 1870, when she was found in the following condition : Motility 
and tactile sensibility in both legs greatly impaired, but the right leg 
is the weaker of the two. Left hand, as measured by the dynamometer, 
is much feebler in power than the right, and this to a more marked 
degree than any normal disparity. Sensations of formication, alternating 
with numbness, of heat and cold, pricking by pins and needles, and 
tingling, still continued in the feet and toes, as also in the hands and 
fingers. Pain in the back increased by pressure and percussion, but no 
burning sensation on applying heat and cold. The anaesthesia is more 
marked in the thighs than in the legs; soreness in the soles of the feet; 
bowels constipated; bladder normal; electro-muscular contractility and 
sensibility greatly diminished. No band around the waist. No spasms, 
twitchings, or reflex movements in the legs. Pain in the lower ex- 
tremities as at first. Changes in the degree of paralysis from time to 
time. Temperature diminished. The circumference of the legs is dimin- 
ished to a marked extent owing to the atrophy of the muscles. Heart 
and lungs healthy; urine not examined." 

At the time, I regarded this case as one of spinal congestion, and 
this was probably an associated condition, but it is very evident that it 



SPINAL PARALYSIS OF ADULTS. 465 

was an instance of inflammation of the anterior tract of gray matter 
chronic in character. The treatment by my direction consisted of elec- 
tricity and ergot, and a complete recovery was the result. 

The case of Elbert Baxter, detailed in the same lecture, was prob- 
ably one of inflammation of the right half of the cord involving the 
anterior tract of gray matter and right posterior column. There were 
paralysis with atrophy of the right lower extremity, and marked anaes- 
thesia and incoordination in the left. This patient also recovered after 
having been under treatment with ergot and electricity at the New 
York State Hospital for Diseases of the Nervous System for over a 
year. 

Another case, likewise a patient in this hospital, and the subject of 
another clinical lecture, was at that time, February 18, 1871, regarded by 
me as an instance of progressive muscular atrophy beginning with con- 
gestion. It is Cases X. and XVII., of those collected by Dr. Seguin, 1 
who saw the patient two days before I did, and who then considered it 
an example of spinal congestion. It is also briefly cited in the former 
editions of this work, 2 and in full in a subsequent publication. 3 

The affection began with pain in the back and sharp, shooting pains 
in the legs, attended with weakness. There was also, at first, some 
headache, vertigo, confusion of ideas, etc. Numbness and loss of power 
existed in both the upper and lower extremities. Subsequently, the 
anaesthesia and paralysis of the upper extremities disappeared. Six 
months afterward the head-symptoms recurred, and there were super- 
added fibrillary contractions in both arms and legs, with a return of the 
numbness. The paralysis of the lower limbs increased to such an 
extent, that the patient was obliged to use crutches, and six weeks later 
he was confined to bed, unable to move any part of his body but his 
head. The bladder and its sphincter were also weakened, though he 
did not lose control of them. The paralysis of the arms again disap- 
peared, but it remained in the legs, and he now noticed that they began 
to be atrophied, and this condition went on advancing. For three years 
he did not walk at all, and during this time the fibrillary contractions 
continued in the legs, though to a diminished extent. He then gradu- 
ally reacquired the power to walk with a crutch. At the time of his 
admission to the hospital his condition, as ascertained by Dr. Cross, was 
as follows : * 

" In the legs the extensors, together with the gastrocnemii and so- 
lei muscles, were found to have almost disappeared, while the atrophy 
in the thigh was distinctly visible, and this loss of power had been 

1 Op. tit, pp. 8 and 10. See note of Dr. Seguin appended to p. 11 of his Memoir. 

* Former editions, p. 666. 

8 " Lectures on Diseases of the Nervous System," New York, 1874, p. 147 — historj 
prepared by Dr. Cross. 

* "Clinical Lectures," p. 150. 

31 



466 DISEASES OF THE SPINAL CORD. 

directly proportioned to the extent of the atrophy. The gait of this 
patient was also highly characteristic of the disease from which he was 
suffering. In walking he lifted his feet high from the ground through 
the action of the flexors of the thigh upon the pelvis, in order to clear his 
toes, which drooped to an extreme degree — and his knees were in this 
way bent to a greater extent than usual. The legs were very much 
reduced in size, and the loss of muscular fibre was quite apparent from 
the greatly diminished electric contractility in these parts. There was 
no atrophy to be discerned in any other part of the body, nor did the 
patient have any head-symptoms whatever, nor had he any loss of motil- 
ity, or any abnormal sensations in his upper limbs. His bowels were 
regular, and he had no trouble with his bladder. There was no loss of 
sensibility, nor were there any sensations of numbness in the legs. His 
heart and lungs were in a healthy state. The reflex excitability was 
diminished in the lower extremities, as was likewise the temperature, 
and the capillary circulation was very sluggish, as was demonstrated by 
the decrease of temperature, which was several degrees below the nor- 
mal standard, and the effect of pressure. There were no fibrillary con- 
tractions present, nor had the patient experienced any electric-like 
pains, cramps, jerkings, or other abnormal sensations for some time. 
The outlines of the fibulae and tibiae, together with the knee-joints, were 
distinctly visible, owing to the destruction of the muscles on the ante- 
rior surface of the leg, while the posterior aspect of the calf was flat- 
tened from a like cause. His back-ache had completely disappeared, 
but, although he felt well and suffered no pain, he appreciated the 
gradual loss of power in his lower extremities. His appetite was good, 
and his mind was very active." 

In his recent memoir, Dr. Seguin classes this case as one of spinal 
paralysis of the adult, in which opinion I entirely coincide. At the 
time I described it, the disease under notice was not distinctly recog- 
nized, and certainly the resemblance to progressive muscular atrophy 
was very great. With locomotor ataxia, to which affection Charcot 2 
assigns it, it has scarcely any thing in common. 

The cut (Fig. 45), owing to the position of the patient when the 
photograph was taken, does not show very well the effect of the disease 
in the legs, but the atrophy of the thighs is distinctly indicated. 

Two cases which I had regarded 1 as instances of " antero-lateral 
spinal sclerosis " were very probably examples of inflammation of the 
anterior tract of gray matter. In one of these, a gentleman whom I 
first saw in consultation with my friend Dr. Walter F. Atlee, of Phila- 
delphia, and who was, subsequently, for a long time under my imme- 
diate charge, the lesion was in the beginning confined to the very 
lowest part of the spinal cord. Gradually the disease extended upward 

1 "A Treatise on Diseases of the Nervous System," New York, 1871 — and subsequent 
?ditions, pp. 475. 47^. 



SPINAL PARALYSIS OF ADULTS. 



467 



until at last, after three years, the muscles of respiration and of deglu- 
tition became implicated, and death took place. But for several months 
before this the patient was unable to use either legs or arms, or even to 
sit up. At no time, however, was the bladder deranged in any respect, 



Fig. 45. 




and at no time were there pains or spasmodic action of the muscles. 
The cutaneous sensibility was scarcely affected, and the atrophy, though 
extensive, was not profound, and did not strike me at the time as 
being very active in character. 

The other case was that of a distinguished legal gentleman of New 
Orleans, sent to me by my friend Dr. Cabell, of the University c f Vir- 
ginia. There was a gradual extension of the disease without any at- 
tendant pains, ansesthesia, or muscular contractions, except to a slight 
extent at first. In this instance also the bladder and rectum escaped. 
This case resisted all treatment. The patient finally went abroad, and 
died soon afterward in London. The atrophy was not a prominent 
feature. 

In another case, that of a gentleman from New Jersey, there was a 
similar condition of paralysis, involving, however, only one lateral half 
of the body, and beginning in the leg. In this case the atrophy was of 



468 DISEASES OF THE SPINAL CORD. 

the most active character, advancing pari passu with the paralysis. 
The flexors and extensors of the foot, and the flexors of the leg, were 
almost entirely destroyed when the patient came under my observa- 
tion. Before I saw him, however, he had consulted several distinguished 
medical gentlemen, who had treated his case as one of tumor of the 
cord or of the vertebral column. This case has already been cited on 
page 474, and is noticed in the previous editions of this work. 1 

In regard to these three cases, I stated in 1871, a " Such cases as the 
foregoing, and several others which have come under my notice, are 
doubtless to be classed with many of those placed under the head of 
what Duchenne has called general spinal paralysis." 

Since 1873 I have had the opportunity of witnessing many cases of 
spinal paralysis of adults. Some of the more striking of these will be 
noticed under other divisions of this section. 

Causes. — In many cases of spinal paralysis of adults, the disease is 
clearly the result of cold, either applied directly to the back as in lying 
on cold, damp ground, or from refrigeration of some part of the surface 
of the body. Relative to this last influence, Frinberg 3 has performed 
an experiment which, if confirmed in its results, will be of a very in- 
structive character. He shaved off the hair from the skin of a rabbii 
and on the unprotected skin threw a jet of the vapor of ether by means 
of Richardson's apparatus. Three days subsequently he repeated this 
operation. About a month afterward the animal was attacked with in- 
continence of urine and paraplegia, and died in a few days. On post- 
mortem examination the whole length of the spinal cord was found in- 
flamed. There was in fact general acute myelitis. In regard to this 
experiment, I can adopt the language of Vulpian, 4 who says : 

" This experiment would be very valuable if the results obtained had 
been observed with a certain number of other animals treated in the 
same manner. Till then we may be permitted to doubt if there really 
was the relation of cause and effect between the refrigeration of the 
skin by the ether-spray and the paraplegia which made its appearance 
a month later." 

Bernhardt's 6 case ensued upon exposure to .cold, as did several of 
Seguin's, and five in my own experience. Meyer's 6 two cases followed 
close on measles. In Rose Peyton, whose case I have related, sudden 
suppression of menstruation appeared to be the cause ; in a number of 
others, blows and falls were alleged as causes, and in others venereal 
excesses, dysentery, syphilis, and violent muscular efforts, seem to have 
been the exciting agencies. In the majority of cases, however, no 

1 Op. czt., p. 476. 9 Previous editions of this work, p. 476. 

3 "Ucber Reflexlahinimgen," Berlin, klin. Wochenschrift, 1871, Nos. 41, 42, 44, 45. 

4 " Lecons sur l'appareil vaso-raoteur," Paris, 1869, tome ii., p. 88. 

5 " TJeber eine der Spinalen-Kinderlahmung ahnlicbe Affection Erwachsener," Arohiv 
fur Psychiatric und NerVenkrankheiten, B. iv., 1873. 6 Op. cit., p. 229. 



SPINAL PARALYSIS OF ADULTS. 469 

cause can be discovered. Such at least has been the fact with the 
instances that have come under my own observation. 

Diagnosis. — Spinal paralysis of adults is to be recognized by the 
facts that the paralysis is often extensive in the first place, and then 
becomes restricted, or that it begins in a limited portion of the body, 
usually in one or both of the lower extremities and then advances ; that 
the paralysis always precedes the atrophy ; that the reflex excitability 
is somewhat impaired or is abolished ; that the electro-muscular con- 
tractility is diminished and the "reactions of degeneration" can be 
obtained ; that there are no bed-sores ; that the disturbances of sensi- 
bility are not usually prominent features ; and that the bladder and 
rectum generally escape. 

It has been often confounded with progressive muscular atrophy, 
but attention to the features above stated will prevent mistakes of the 
kind. In progressive muscular atrophy, it must be borne in mind that 
the atrophy is the essential feature, and that the loss of power results 
from the diminished size of the muscles, while it is the most rare oc- 
currence to find the " reactions of degeneration " present. 

In acute general myelitis the paralysis of the bladder and sphincter 
ani, the tendency to bed-sores, the spasmodic movements of the limbs, 
the great disturbances of sensibility, the sensation of constriction around 
the body, and the greater constitutional commotion, will serve for the 
identification of the disease. In the partial form of acute myelitis the 
distinctive features are equally as marked. 

Hallopeau ' has reported a number of cases under the head of chronic 
diffused myelitis, which were undoubtedly instances of spinal paralysis 
of adults, judging both from their symptoms and morbid anatomy, and 
the author admits as much when he says : 3 

" The remarkable lesions [brown discoloration, no microscopical ex- 
amination being made] which we found in the anterior horns permit us 
to think that, as in the cases of MM. Charcot and Joffroy, histological 
alterations would have been discovered." 

The distinction between the acute, the subacute, and the chronic 
forms of spinal paralysis of adults is not one of kind but only of de- 
gree, and the same may be said of the acute ascending paralysis of Lan- 
dry, on which I have already insisted. The fact that in the latter form 
of the disease the respiratory muscles are affected, is of course only due 
to the circumstance that the morbid process has reached the medulla 
oblongata. In regard to this variety, Dr. Seguin says : " There is an 
affection running its course in ten or twenty days, characterized by 
symptoms almost identical with those of subacute spinal palsy. There 
is an akinesis, without much ansesthesia, first appearing in the feet and 
legs, then ascending and involving the entire trunk and limbs, produc- 

1 "Etudes sur les myelites chroniques diffuses," Archives Generates, 1871-'72. 
9 Op. cit, tome i., 1872, p. 72. 



470 DISEASES OF THE SPINAL CORD. 

ing, in nearly all cases, death by asphyxia. It is upon this palsy of the 
respiratory muscles that the diagnosis of this most fatal disease, acute 
ascending paralysis, is to be made from spinal paralysis." 

Now, if in any case the progress of the disease had been arrested at 
a point of the spinal cord half an inch below the decussation of the an- 
terior columns, the diagnostic mark of Dr. Seguin would have been 
absent, and the distinction between the form in question and spinal pa- 
ralysis of adults could not have been made. The mere fact of the im- 
plication of the respiratory nerves cannot, in my opinion, be made a 
ground for assuming a separate nosological position for acute ascend- 
ing paralysis any more than the circumstance of the brachial plexus be- 
ing reached in any case should make a distinct form. Dr. Seguin does 
not appear to recognize the fact that the acute ascending paralysis of 
Landry is identical with the subacute general anterior spinal paralysis 
of adults, although he very distinctly admits the relationship. 

Petitfils * has entered at length into the consideration of the question 
of the identity of the acute and subacute forms, and has very satisfac- 
torily shown, both from the symptoms and the morbid anatomy, that 
no essential difference between them exists. 

From spinal congestion the spinal paralysis of adults is discriminated 
by the facts that, in the former the sphincters are usually affected, that 
the paralysis is not generally complete in any part of the body, by the 
absence of atrophy, and by the general presence of disturbances of vis- 
ceral functions. In the first stage, however, of either affection, it must 
be admitted that very striking resemblances exist, and time may be 
necessary for the diagnosis to be made with accuracy. Thus, in a case 
which I saw a few days since, in consultation with Dr. Newcomb of this 
city, there had been, in the first place, a set of symptoms present which, 
had I then seen the patient, would have induced me to regard it as one 
of spinal congestion. When the man, a stage-carpenter, came to me, 
however, the paralysis and atrophy of the right lower extremity, the 
diminished temperature of that limb, and the absence of bladder- 
troubles, left no doubt on my mind relative to the case being one of 
spinal paralysis in the adult. 

A case reported by Dr. Cuming, 2 of Belfast, which presented all the 
essential features of spinal paralysis of adults, was regarded by him as 
one of spinal congestion. The patient, a man aged forty, observed on 
a cold night that his hands had become numb and white, and when he 
reached home he had not the use of them. A few days afterward he 
fell asleep on a cold wall, and when he awoke found the numbness in- 
creased. In a few days he was entirely deprived of the power of mo- 

1 " Considerations sur l'atrophie aigue des cellules motrices," Paris, 1878, p. 83. 

a " Case of Extensive Paralysis from Morbid Condition of the Spinal Cord, probabl j 
Congestion," Transactions of Ulster Medical Society, Dublin Quarterly Journal of Medi 
-nil Science, vol. xlvii., 1869, p. 471. 



SPINAL PARALYSIS OF ADULTS. 471 

tion in all parts below the neck. But he soon began to regain the use 
of his limbs, and at the end of two years could walk well. The upper 
extremities were, however, wasted, and he had the main en griffe. 

The diagnosis, therefore, should not be hastily made. 

Prognosis. — So long as the lesion does not attain to the height of 
the respiratory nerves, the prognosis, as regards the life of the patient, 
is not unfavorable. Indeed, recovery, with a more or less extensive loss 
of power, with atrophy and deformity, is the rule, and in some cases 
there is a complete restoration of motor power and muscular integrity. 
Even when the morbid process reaches the height of the respiratory 
nerves, life may be preserved, and complete restoration may take place. 
This was the case with the instance already cited reported by M. La- 
badie-Lagrave, and in two in my own experience, which will be fully 
cited under the head of treatment. Sometimes the process of recovery 
begins within a few days, and goes on uninterruptedly till complete 
restoration is the result. 

When seen at a later stage, when the paralysis and atrophy are 
limited, the prospect of cure or improvement depends altogether on the 
condition of the muscles as regards their electric contractility. If the 
affected muscles can be made to contract with either the induced or 
primary current, recovery will, in all probability, take place. But, when 
this action cannot be brought about, there is no hope. The principles 
of the prognosis are, therefore, identical with those which exist in the 
infantile form of the disease. 

Morbid Anatomy and Pathology. — There is not much to add under 
this head to the remarks made on the same subject in regard to infan- 
tile spinal paralysis. The characteristics of the disease have, as we have 
seen, sufficed to place the lesion in the anterior tract of gray matter, and 
this theory, based upon physiology and the analogy of the affection 
with infantile spinal paralysis, has been definitely confirmed by post- 
mortem research within the past three years by Gombault, 1 one of the 
pupils of the Salpetriere. 

The patient, aged sixty-seven on the 1st of January, 1865, was 
seized suddenly with a paralysis of all four extremities, beginning in 
her legs and extending to the arms as a numbness and heaviness. 
Within half an hour she could not stand. There were no antecedent 
phenomena, she having been in perfect health up to the moment of the 
attack. There was no paralysis of the tongue, muscles of deglutition, 
or respiration. The bladder and rectum were also unaffected, and the 
cutaneous sensibility remained intact. 

The paralysis of the limbs soon became complete, and in fifteen days 
she was taken to the hospital. There was slight febrile disturbance, 
but at no time were there bed-sores. 

1 " Note sur un cas de paralysie spinale de l'adulte suivi d'autopsie," Archives de Phy- 
siologic, tome v., 18Y3, p. 80. 



472 DISEASES OF THE SPINAL CORD. 

After two years passed in complete immobility, the patient recov- 
ered, to some extent, the use of her limbs. The amendment began in 
the upper extremities. When she entered the Salpetriere, five and 
a half years after the inception of the disease, she could walk imper- 
fectly with a cane. During the first year of her stay in the hospital she 
improved so that she was able to dress herself, and to take short walks 
in the court-yard. 

On the 13th of May, 1872, examination showed that the thenar emi- 
nences had entirely disappeared, the interosseous muscles were atro- 
phied, there was the main en griffe / the muscles of the forearms, arms, 
shoulders, neck, and chest, were atrophied. 

In the lower extremities the left calf was most atrophied, and was 
soft and flabby ; the thighs were unaffected. 

The electro-muscular contractility was entirely abolished in the hands 
and forearms, impaired in other parts of the upper extremities, and in 
the legs. The cutaneous sensibility was preserved. 

The patient soon afterward died of another disease. 

On post-mortem examination the membranes of the brain and cord 
were found to be healthy, and to the naked eye there was no lesion of 
either of these organs. 

The histological examination of the spinal cord was made after 
hardening in solution of chromic acid and coloring with carmine. 

The white substance throughout all its extent exhibited no traces of 
disease. Only the columns of horizontal fibres which emerge from the 
anterior horns to form the fibres of origin of the anterior roots showed 
a notable diminution in size. The posterior commissure and posterior 
horns were normal. The lesion was almost entirely confined to the 
area of the anterior horns, and here it only concerned the large nerve- 
cells called motor-cells. The walls of the vessels had suffered no change; 
they were of normal thickness, and the sheath was free from granular 
bodies. Moreover, there was not in the neuroglia any trace of the ex- 
istence of an irritative process such as a proliferation of the neuroglia. 

As to the alteration of the nerve-cells, it was such as is met with in 
progressive atrophy of these elements — yellow pjgmentation. The le- 
sion was diffused; it had struck here and there the nervous elements, of 
which a certain number had disappeared, for in some sections only fif- 
teen or twenty could be counted. 

The cells which did not exhibit this yellow pigmentation were 
nevertheless reduced in size. 

This was the first full investigation made relative to the morbid 
anatomy of spinal paralysis of adults; but, previous to Gombault's re- 
searches an examination of a patient who had died of ascending paraly- 
sis, and in whom lesions of the anterior horns were discovered, was re 
ported by Chalret. 1 

1 "These de Paris," 1872. cited by Gombauli. 



SPINAL PARALYSIS OF ADULTS. 473 

The data are, therefore, quite sufficient to enable us to place spinal 
paralysis of adults in a definite patho-anatomical position as depending 
upon inflammation of the anterior tract of gray matter and the conse- 
quent atrophy and disappearance of the cells constituting its nervous 
elements. 

In regard to the questions entering into the pathology of the dis- 
ease under notice there is nothing to bring forward in addition to the 
facts and arguments already adduced under the head of infantile spinal 
paralysis. 

Treatment. — The treatment of spinal paralysis of adults admits of 
division into two parts, that which is proper for the first or acute stage, 
and that advisable for the second or chronic stage. 

I have had the opportunity of treating four cases of the disease in 
question from the very beginning, with the result in each case of arrest- 
ing the progress of the disease and preventing any subsequent atrophy 
of the limbs. Two of these were of the most severe type of this affec- 
tion, and I therefore report them with some degree of fullness, as ex- 
emplifying the therapeutical principles which in my opinion should 
govern. 

A. G. S., aged about thirty-five, after rising one morning and 
moving about the room, felt a slight degree of weakness in both lower 
extremities. This increased through the day, and by night he was un» 
able to stand. The next morning he felt similar weakness in both arms 
and in a few hours was deprived of their use. He was out of the city 
at the time, but he was brought here, and I saw him on the fourth day. 
He was then perfectly helpless from complete paralysis of all four 
limbs. There were no aberrations of sensibility, no paralysis of the 
bladder or sphincters, no motor spasms anywhere. Reflex excitability 
was abolished in all the paralyzed parts, and the electro-muscular con- 
tractility was greatly diminished especially in the muscles of the legs. 
The breathing, deglutition, articulation, and motility of the neck and 
face, were unaffected. The mind was as clear as ever. There had been 
slight fever, but this had disappeared when he came under my observa- 
tion. There was no history of syphilis. 

I immediately began the treatment with the iodide of potassium in 
doses of ten grains three times a day, increased gradually, and the 
fluid-extract of ergot in doses of a drachm, to be taken also three times 
a day. 

On the following morning there was some difficulty of respiration 
and of deglutition, and the movements of the tongue were a little awk- 
ward. The irregularity and shortness of breathing increased through 
the day and night, and when I saw him the next morning there was 
great discomfort on this account. The action of the heart was also 
considerably disturbed, and there were frequent interruptions in the 
pulse. On the seventh daj 7 of the disease he suddenly became para- 



474 DISEASES OF THE SPINAL CORD. 

lyzed on both sides of the face, the right being more severely af- 
fected. 

During all this time the iodide of potassium and ergot had been per- 
sistently given, the latter, on the appearance of the bulbar symptoms, 
having been increased to two drachms four times daily. 

On the ninth day of the disease there was a slight amelioration in 
the phenomena due to the implication of the medulla oblongata. The 
respiration became easier, the deglutition less difficult, the articulation 
more distinct, and the facial paralysis of the left side began to disap- 
pear. He was able to close the eye of that side and to elevate and 
corrugate the brows. 

On the tenth day the facial paralysis of both sides had nearly disap- 
peared, and the patient was able to breathe freely, to talk well, and to 
swallow without inconvenience. There was also a slight return of 
motility in the lower extremities. The toes could be moved and the 
feet flexed. 

The galvanic current, interrupted rapidly, was now applied to the 
muscles of both npper and lower extremities for half an hour every day, 
at the same time that the internal medication was continued. The limbs 
were also well kneaded, and passive motions made with them frequently. 

On the thirteenth day his condition was as follows : He could move 
both lower extremities while lying in bed — performing with slowness, 
but yet with precision, all the movements of which the parts were 
capable. The arms could not yet be moved, but be could slightly 
extend and flex the fingers of both hands. The bulbar symptoms had 
entirely disappeared. Reflex excitability and electro-muscular contrac- 
tility were good, except that it required strong galvanic currents to 
cause contractions in the anterior tibial and peroneal muscles of both 
legs. All the other muscles reacted well to the faradaic current. The 
ergot and iodide of potassium were now discontinued. 

His improvement went on, and by the end of the fourth month he 
could walk a mile or more, and use his hands and arms well. There was 
slight atrophy of the muscles of the calves, but nowhere else. The 
faradaic current was still employed daily, and un,der its use he became 
stronger, till at the end of a year he was not conscious of any weakness 
in any part of his body. He has continued and now is perfectly well, 
and was kind enough to allow me to make him the subject of a clinical 
lecture a few days ago at the University Medical College. 

B. B., aged forty-five, was attacked with gradually-increasing pa- 
ralysis of the right side, beginning in the leg, and gradually advancing 
during several months, till it involved the whole of the lower extremity 
and arm. At no time, however, was the loss of power complete. He 
went to the Warm Springs of Arkansas, but did not improve. Return- 
ing to New York in April, 1875, and his disease becoming worse, I was 
requested tn take charge of his case. 



SPINAL PARALYSIS OF ADLLTS. 475 

When I saw him there was such a degree of paralysis of the right 
lower extremity that he was unable to walk without assistance — the 
arm of that side was nearly useless. The respiration was labored and 
irregular ; he was almost unable to swallow, and would not eat, on 
account of the great distress produced by all attempts at deglutition — 
the tongue could not be protruded, and his articulation was unintelligible. 
Owing to his inability to swallow, the saliva ran in streams from his 
mouth, and, as he could not cough without great and painful effort, the 
mucus accumulated in his air-passages, and caused danger of suffoca- 
tion. It was removed from time to time from the pharynx by the 
ringers of his nurse. There was moderate febrile excitement. 

Although the paralysis was more marked on the right side, I ascer- 
tained that the left was also affected. Tickling the soles of the feet 
caused no reflex movements. Electro-muscular contractility was greatly 
impaired on the right side, and weakened quite notably on the left. 
There was no facial paralysis ; no bladder or sphincter trouble ; no 
bed-sores ; no derangement of sensibility ; no pains, and no muscular 
spasms. 

At no time had there been any mental disturbance, except great 
emotional weakness and irritability of temper. The intellect was per- 
fectly intact; the memory perfect. 

The iodide of potassium was given as in the previous case, but was 
combined with the bromide in doses of fifteen grains. Ergot, in the 
form of the fluid-extract, was also administered. I requested my friend 
Dr. Clinton Wagner to make a careful examination of the throat, and 
to take charge of him, so far as the immediate management of his 
throat-symptoms was concerned. He found the fauces, pharynx, and 
larynx congested, and the vocal cords partially paralyzed. He recom- 
mended steam inhalations, and they were used, with the effect of giving 
great relief by detaching the mucus and rendering it more fluid. 

As the difficulty of swallowing increased, I made preparations to 
feed the patient through a stomach-tube. The efforts at respiration 
became more painful, and at times I thought death by asphyxia immi- 
nent. The tongue was now immovable, lying like a flabby, reddened 
mass in the mouth, and the patient lay in bed entirely helpless through 
the paralysis of his limbs. But now amendment began, and, as in the 
case just cited, with the gradual disappearance of the bulbar symp- 
toms. Little by little improvement took place. Faradization was 
now brought into use, and was employed daily to the tongue, throat, 
and extremities, while the internal medication was continued. By the 
first of June he was able to use his legs in standing, and his arms 
and hands to support himself. He could not yet, however, employ 
them in feeding himself. About the first of July he could walk with 
a cane, and used his hands well. He went to Saratoga the middle of 
July, and while there had a relapse, consisting in a sudden paralysis 



476 DISEASES OF THE SPINAL CORD. 

of the left lower extremity, by which he was again deprived of the 
ability to walk. He was there attended by Drs. Whiting and Lente, 
and I also visited him. The iodide of potassium, which had been dis- 
continued, w^as resumed. Under its use, with ergot, hypodermic injec- 
tions of strychnia, and faradism, he has again acquired the power of 
walking, though his improvement, owing to considerable atrophy of the 
muscles of the legs, especially the gastrocnemii, is slow. 

It may be mentioned, incidentally, that after he began to lose power 
in his legs, he fell, upon one occasion, and struck his right side violently 
against the edge of a wooden bucket. After he was able to go out, I 
made a careful examination, and, detecting fluctuation in the liver, I 
removed about a pint of pus with the aspirator. No unpleasant symp- 
toms followed, and there was no reaccumulation of the pus. 

The treatment, therefore, which in my opinion is best adapted to 
the initial or advancing stage of spinal paralysis in the adult, is that 
which consists in the persistent use of the iodide of potassium and 
ergot, both given in large doses. The former I carried, in both of the 
cases cited, to half an ounce daily, and the latter to an ounce. Dr. 
Seguin ' reports a case, as occurring in the practice of Dr. T. A. 
McBride, and which he saw in consultation, in which the fluid-extract 
of ergot was given in like quantity daily, and in which recovery ensued. 
This treatment is based upon the theory that the first stage of the dis- 
ease in question is characterized by a congestion limited to the anterior 
tract of gray matter. 

As soon as the muscles show the slightest sign of regaining their 
power, electricity should be employed. The form in which it should be 
used depends entirely on the requirements of each individual case. If 
the faradaic current will cause contractions in the paralyzed muscles, it 
is the preferable form, but if not, then the interrupted primary or gal- 
vanic current must be applied and used in such a degree of intensity as 
will cause muscular contractions. 

In one of the other cases of the four which I have treated, while the 
disease was advancing, I used the actual cautery to the spine — applied 
over the seat of the disease, as near as could be, determined from the 
extent of the paralysis. The effect was apparently excellent, the lesion 
ceasing to advance. But one such case cannot be regarded as afford- 
ing more than an indication. From what I have seen, however, of the 
power of the actual cautery in other affections of the cord, I should be 
disposed to employ it in future like cases of spinal paralysis of adults. 
In the later or chronic stage, as will be presently shown, it is certainly 
of great value. 

After the progress of the disease is arrested, the treatment which is 
most advisable consists in the persistent use of electricity to the para- 
lyzed muscles, with the view of restoring motility and preventing or 
1 Op. cit., p. 22, Case XXII. 



SPINAL PARALYSIS OF ADULTS. 



477 



curing atrophy ; the hypodermic injections of strychnia in gradually- 
increasing doses, till the physiological effects of the drug are pro- 
duced, when the doses should be diminished, and again increased, 
and so on ; and repeated applications of the actual cautery to the 
spine. Three or four applications are made at one sitting on each 
side of the spinous processes, and over the part which is in physio- 
logical relation with the paralyzed regions. 

I have never seen a case of spinal paralysis of adults which was 
entirely unamenable to this treatment, and the majority recover com- 
pletely. In the accompanying woodcut (Fig. 46) is the exact appear- 




ance of the legs of a woman who consulted me September 20, 1874, 
and who had suffered an attack of the disease under consideration 
some three years previously. As will be seen, the calves are atrophied 
to an extreme degree, and her walking was correspondingly impaired. 
She was treated with the galvanic current in the first place, and subse- 
quently with the faradaic. Strychnia was injected into the limbs daily, 
according to the method mentioned, beginning with the thirtieth of a 
grain, and the actual cautery was applied to the lower dorsal and upper 
lumbar region of the spine six times. In less than three months she could 
walk as well as she ever did, and her calves, from having measured each 
only eleven and a half inches at their largest circumference, had in- 
creased to fifteen inches in the right, and fifteen and a half in the left. 
Electricity has been very generally employed by those physicians 
who have recognized the disease in question. Thus Bernhardt 1 re- 

1 "Ueber eine der spinalen Kinderlahmung ahnliche Affection Erwachsener," Archiv 
fur Psychiatrie und Nervenkranklieiten, Band iv., Heft 2, 1873, p. 370. 



478 DISEASES OF THE SPINAL CORD. 

ports a case of recovery mainly through its agency, as do also Eiscn- 
lohr, 1 a case from Friedreich's clinic ; Frey, 2 three cases from Kiiss- 
maul's clinic in Freiberg ; Seguin, 3 several cases, in which electricity 
was a part of the treatment, and with good results ; Lincoln, 4 com- 
plete recovery after marked atrophy ; Leyden, 6 a bad case with partial 
recovery, so as to be able to walk with crutches a little better than he 
could before treatment ; and cases mentioned by Duchenne. 6 

In my own practice, I have treated a good many cases with elec- 
tricity alone — cases in which the paralysis and atrophy were limited, 
and have rarely been disappointed in the results. In one very notable 
case, sent to me by my friend Dr. Christopher Johnston, of Baltimore, 
the gastrocnemius was rapidly regenerated through the agency of the 
interrupted galvanic current, so that the strength could be measured 
daily by means of an apparatus devised by the patient, and the im- 
provement accurately ascertained. 

With the electricity, passive movements and kneading are always 
useful, and the patient should be encouraged to use the affected mus- 
cles up to the point of fatigue, at repeated times during the day. 

2. Inflammation of the Motor Cells. 

Thus far, only one disease of this class has been differentiated, and 
it is characterized by paralysis of the parts involved, without atrophy. 

a. Glosso-JLabio-Laryngeal Paralysis. 

The first explicit account of this very remarkable disease is that of 
Duchenne, 7 who, in consideration of the tendency of the morbid pro- 
cess to advance unchecked, and of the parts affected, designated it 
" progressive muscular paralysis of the tongue, the veil of the palate, 
and the lips." The consequences of this condition, as pointed out by 
Duchenne, are difficulties of articulation and of deglutition, and at a 
late period of the disease frequent attacks of strangulation, during 
one of which the patient may die ; or death may result either from 
inanition or syncope. 

But, although Duchenne was the first to give a systematic descrip- 

1 " Zur Lehre von der acuten spinalen Paralysie," Archiv fur Psychiatric u. s. w., 
Band iv., 1874, p. 219. 

2 "Ueber temporare Erwachsener, die der temporarcn Spinallahmung der Kinder 
analog sind, und von Myelitis der Vorderhorner auszugehen seheinen," Berliner Minische 
Woclmischrift, Nos. 1-3, 1874. 

3 Op. til, Cases XIX., XX, XXII. 

4 "A Case of Spinal Paralysis in an Adult, resembling the so-called Infantile Pa- 
ralysis, 1 ' Boston Medical and Surgical Journal, March 25, 1875. 

6 "Klinik der Nervenkrankheiten," zweiter Band, Berlin, 1875, p. 199. 

6 Op. cit, p. 458. 

7 "De l'electrisation localisee," etc., deuxieme edition, Paris, 1861, p. 621. 



GLOSSO-LABIO-LARYXGEAL PARALYSIS. 479 

tion of the affection, it was observed by Dr. F. W. Robinson, in 18.25, 
who thus writes to Sir Charles Bell: ' "In consequence of your impor- 
tant discoveries relating to the nerves, I am particularly desirous to have 
your opinion in the following case: The invalid is an unmarried lady, 
nearly seventy years of age, who has enjoyed uninterrupted good health 
up to the present illness. She has had occasional short attacks of gouty 
rheumatism in both feet and also in the knees, of very short duration. 
From the first of her complaining up to the present moment, she has 
been free from headache, and from pain, numbness, or debility of the 
limbs. The vision and hearing are natural, the appetite good ; the 
bowels regular, and the sleep natural. In short, there is not the slightest 
deviation from sound health except in the particulars I shall relate. 

" Some few months ago she had some difficulty in using the tongue, 
and in expressing particular words. This difficulty has gradually in- 
creased, and now she cannot protrude the tongue or even move it. She 
has lost her speech altogether. The tongue itself is soft and pulpy, but 
it retains its sense of taste and of feeling. The deglutition is impaired, 
and occasionally she is distressed with a sense of suffocation in attempt- 
ing to swallow food, which now she is obliged to do with great care. 
She cannot hack up any thing from the throat nor draw any thing from 
the posterior nares by a back draught. The features of the face are 
quite natural, and the skin retains its feeling. The saliva occasionally 
flows from the mouth." 

This is certainly a very accurate description of a case which, although 
its real nature was not recognized at the time, was undoubtedly an in- 
stance of the disease under notice. 

Then Trousseau in 1841, just twenty years before the publication of 
Duchenne's account, recognized it as an affection he had not previously 
seen, and wrote a memorandum of the existing phenomena. 2 Trousseau 
named the disease glosso-laryngeal paralysis, in his lecture on the sub- 
ject, and this was afterward amplified by Duchenne into glosso-labio- 
laryngeal paralysis. Many cases have been subsequently reported, and 
descriptions of the affection given, but no one has added any thing to 
the graphic symptomatology of Duchenne. 

Fifteen cases of the disease have come under my observation during 
the past ten years. 

Symptoms. — It rarely happens that patients seek medical advice for 
the initial symptoms of the disease under notice. We are therefore, in 
general, obliged to rely on their accounts of the order and progress of 
the symptoms. In one instance only — and this patient is still under 
treatment — have I had the opportunity of observing a case from a very 
early point in the course of the disease. 

The first evidence of disease, which in the majority of instances at* 

1 " The Nervous System of the Human Body," London, 1830, p. cxvii. 
* "Lectures on Clinical Medicine," Bazire's translation, p. 117. 



480 DISEASES OF THE SPINAL CORD. 

tracts the attention of the pat ; ent, is a slight difficulty of articulation, 
due to a want of rapidity and exactness in the movements of the tongue. 
This circumstance occurred in eleven of my cases. In the others the 
symptom first noticed was a tendency in the lips to remain separate, 
and the consequent necessity of using some degree of mental action to 
keep them closed. In a short time the restraint in the motions of the 
tongue becomes more distinctly marked, and it is especially character- 
ized by an inability to raise the extremity to the roof of the mouth, or 
to press it against the upper teeth. The words, therefore, which the 
patient experiences most difficulty in pronouncing distinctly are those 
which begin with lingual or dental consonants. The gutturals he can 
articulate without trouble ; and the labials, except when the affection 
begins in the lips, do not yet give him inconvenience. 

The next symptom to make its appearance is difficulty of swallow- 
ing. The food is not promptly grasped by the constrictor muscles of 
the pharnyx, and the tongue does not press it strongly against them. 
At times it enters the pharynx, and, not being carried onward by the 
muscles of deglutition, may slip into the larynx and occasion suffocation. 
Liquids are especially difficult to swallow, and are often ejected through 
the nostrils. 

As the result of this paralvsis of the muscles of deglutition, the 
saliva, instead of being swallowed as fast as secreted, accumulates in 
the mouth. Here it becomes stringy from its mixture with the buccal 
mucus, and when the patient opens his lips it runs out in streams. 
After a time the orbicularis oris becomes so far paralyzed that the lips 
cannot be kept closed without continual exertion, and then the viscid 
saliva is constantly flowing out of the mouth. In four of the cases 
mentioned as being under my charge, there was from the first some 
flow of saliva from the mouth, not apparently from any difficulty of 
swallowing, but from the existing paralysis of the orbicularis oris allow- 
ing the mouth to be almost constantly open. The other muscles sup- 
plied by the facial nerve in the lower part of the face, singularly enough, 
do not become involved. The food, it is true, accumulates between the 
gums and the cheeks, and has to be removed with /the finger, but this is 
not due to any paralysis of the buccinator muscles, but to the want of 
power in the tongue to move the alimentary bolus around the cavity of 
the mouth. 

When the disease is thus fully developed by the paralysis of the 
tongue, the veil of the palate, and the lips, the patient presents a pitia- 
ole spectacle. He is unable to talk ; his teeth are exposed, from the 
impossibility of closing his mouth ; the saliva either runs in streams 
over the lower lip, or he goes about with a handkerchief in his hand 
which he uses to absorb the perpetual flow ; every attempt at degluti- 
tion causes him the utmost distress, and puts him in danger of his life 
from strangulation. When he opens his mouth the glutinous saliva is 



GLOSSO-LABIO-LARYNGEAL PARALYSIS. 



481 



seen hanging in viscid strings from the roof, and his tongue, which 
he cannot move, lies torpid, like an inert mass of muscles as it is. 

The facial expression is well seen in the accompanying woodcut 
(Fig. 47), made from a very accurate sketch of one of my patients suf- 



Fig. 47. 




fering from the disease in question, and who entered my consulting- 
room with his handkerchief to his mouth to absorb the streams of saliva 
which were flowing. 

The condition of the patient becomes still more painful from the im- 
plication of the respiratory muscles. The walls of the chest become 
paralyzed, and he is unable not only to breathe deeply, but to cough so 
as to keep the bronchial tubes clear of accumulations of mucus. So 
feeble is the respiratory power, that with all the effort he can make he 
cannot blow out a candle. 

And, besides the impossibility of articulation, the larynx becomes 
paralyzed at a later period of the disease, and phonation becomes im- 
possible. The patient is then doomed to perpetual silence, even the 
power of whispering being lost. 

A remarkable fact is characteristic of many cases of glosso-labio- 
laryngeal paralysis, and that is the tendency of the morbid action to 
extend so as to implicate other nerve-cells lower down in the spinal 
32 



482 DISEASES OF THE SPINAL CORD. 

cord. But the cells thus affected are not motor, but trophic, and 
as a consequence the resulting condition is not paralysis but mus- 
cular atrophy. In none of my cases was there muscular atrophy 
in any part of the body, but in one, to be presently referred to 
more at length, there was incipient paralysis of the right arm. 
The case was, therefore, similar to the one reported by MM. Du- 
chenne and Joffroy, and which will be more specifically referred to 
hereafter. 

The reflex excitability, so fully developed in the fauces, gradually 
diminishes, and is finally lost altogether. 

In some instances atrophic changes unquestionably occur. In such 
cases bundles of muscular fibres here and there in the tongue undergo 
an atrophic degeneration, which, when that organ is protruded, gives 
a " gouged ' ? appearance to its surface. Electrical reactions of degen- 
eration can usually be obtained. 

Gradually, as the disease advances, the physical powers of the pa- 
tient yield. He becomes unable to walk, not from paralysis, but from 
general debility, due to insufficient nutrition and imperfect respiration. 
His appetite remains good, but he is afraid to take any more food than 
is barely sufficient to sustain life, for experience has taught him that 
suffering and danger are attendant on every attempt at deglutition. 
At last he ceases to make the effort, and is fed with liquid food through 
a stomach-tube. The saliva during sleep runs down his throat, and fits 
of suffocation are the result. Too weak to walk, he remains in bed, 
his head turned to one side so as to allow free egress for the saliva, and 
he dies either from asphyxia, from the cessation of the action of the 
heart through the continued extension of the lesion to the cells sup- 
plying the pneumogastric nerve, or from some intercurrent affection. 

Generally the mind remains clear to the last, but in a very interest- 
ing instance of the disease occurring in an officer of the army, sent to 
me by my friend Dr. Fleming, of Pittsburg, this was not the case, 
manifest dementia making its appearance toward the close. The emo- 
tions are, however, almost invariably easily excited. 

The first case of this disease coming under my observation was one 
referred to me, over eight years ago, by my friend Dr. Edward Bradley, 
of this city. The patient was a watchmaker, and very intelligent. 
Though unable to speak a word, I obtained a good deal of information 
from him relative to his disease by asking him questions, the answers 
to which he wrote. The accompanying facsimile of one of his writ- 
ten communications to me (Fig. 48) will, I doubt not, prove of interest. 
It was made partially in answer to questions, and partially at his own 
suggestion. The date (March, 1847) was given in answer to my ques- 
tion when the disease appeared, and the year mentioned is a mistake 
for 1867. As he states, there was a little trouble with his right arm. 
This was of the nature of paralysis, there being no muscular atrophy 



GLOSSO-LABIO-LARYNGEAL PARALYSIS. 483 




484 



DISEASES OF THE SPINAL CORD. 



anywhere. The patient died about six months after I saw him, the 
disease lasting a little over a year. 

Another case — the eighth — was a patient in the New York State 
Hospital for Diseases of the Nervous System. In him the affection 
began in the orbicularis oris, and gradually involved the tongue and 
muscles of deglutition. The left side was first affected, and then, a 
few weeks afterward, the paralysis extended to the right. There was 
nystagmus of both eyes. The mind was perfectly clear. He formed 
the subject of a clinical lecture on glosso-labio-laryngeal paralysis, 
which I delivered during the session of 1870-'71, at the Bellevue Hos- 
pital Medical College. The case is further remarkable as occurring in 
an exceptionally young person, the patient being but thirty-two years 
of age. Duchenne i states that he has never observed it in persons 

Fig. 49. 




under forty. I subjoin a representation of this patient (Fig. 49), 
taken from a photograph. The paralysis of the orbicularis oris is evi- 
dent, although it is partly concealed by the mustache. At the time 
it was taken the patient could swallow, but was conscious of a diffi- 
culty in beginning the act of deglutition. 

In this case the first symptom observed by the patient was a marked 

1 " De V electrisation localisee," Paris, 1861, p. 648. 



GLOSSO-LABIO-LARYNGEAL PARALYSIS. 



485 




anaesthesia of the face and lining membrane of the cheek on the left 
side. Krishaber ' has since reported an instance of like character, and 
regards the loss of sensibility as a valuable precursory sign, and as ex- 
hibiting in a very striking manner the physiognomy of the disease. 

I subjoin the engraving (Fig. 50), from a photograph, repre- 
senting a patient who came from the West to consult Dr. Sayre and 
myself. He entered my consult- 
ing-room holding his handker- Fig. 50. 
chief to his mouth, to catch the 
streams of saliva which were pour- 
ing from it, unable to speak a 
word and scarcely able to swallow. 

Causes. — The etiology of glosso- 
labio-laryngeal paralysis is very 
obscure. Duchenne attributes one 
of his cases to mental anxiety ; 
two cases appeared to be due to 
syphilis and rheumatism. In no 
other instance could he assign a 
cause. 

Of my own cases, one was ap- 
parently due to business troubles 
resulting from petroleum specula- 
tions ; and, in one, excessive application to business appeared to be 
the cause. In one other case, that of a gentleman of this city, the 
disease was evidently associated with syphilis ; and in one it was 
apparently caused by a blow on the back of the head, and in one by 
exposure to a strong draught of cold air, which blew directly on the 
nape of the neck and occiput. In none of the others could I assign any 
cause. All of my patients were between the ages of forty and sixty, 
except the one whose case and portrait (Fig. 50) have been given. 

Diagnosis. — Attention to the account of the symptoms given will 
prevent any mistake in diagnosis, as there is no affection which re- 
sembles in its entirety the one under consideration. In the very early 
stage, however, it may be confounded w 7 ith simple paralysis of the 
tongue ; or, if the disease begins in the lips, as in the case cited, with 
facial paralysis. In glossoplegia there are other symptoms of cere- 
bral disorder, and in facial paralysis the loss of power is not confined 
to the lips. 

It may possibly, in some cases, not be distinguished from the gen- 
eral paralysis of the insane, which generally begins with paralysis of 
the tongue and weakness of the lips. The facts that this disease is 
manifested also by mental symptoms, and that the paralysis gradually 

1 " Ansesthesie de la sensibilite reflex des voies aeriennes et digestives, comme pre- 
curseur de la paralysie labio-glasso-laryngee," Gazette hebdomadaire, November 29, 1872 



486 DISEASES OF THE SPIXAL CORD. 

involves the other muscles of the body, will suffice for making an exact 
diagnosis. In facial diplegia the expression of countenance is very 
much like that of a patient suffering from glosso-labio-laryngeal paraly- 
sis, but here the resemblance ends, and careful examination shows even 
here many points of difference. It is only necessary to state that the 
tongue is not paralyzed, and that there is no difficulty of swallowing in 
double facial paralysis. 

In progressive muscular atrophy, attacking the tongue, the veil of 
the palate, and the lips, a mistake might also be made. But, as Du- 
chenne remarks, progressive muscular atrophy rarely begins in that 
way, and, when it does, other muscles of the body, especially the the- 
nar and hypothenar eminences, will soon become involved. Charcot 
has, however, recently reported a case, to be presently more fully quoted, 
in which progressive muscular atrophy was clearly combined with glos- 
so-labio-laryngeal paralysis, and in which, on post-mortem examina- 
tion, though the volume of the tongue was not diminished, the muscu- 
lar fibre had undergone degradation. In such a case, of course, a 
complete diagnosis could only be made after death. In ordinary pro- 
gressive muscular atrophy, the fact that the atrophy comes on before 
the paralysis, is to be borne in mind. 

From diphtheritic paralysis attacking the muscles of the pharynx, 
glosso-labio-laryngeal paralysis is readily distinguished by inquiries 
relative to the history of the case, and by the fact that the tongue is 
not involved in the first-named disorder. 

Prognosis. — There is no instance on record of a cure. 

All my patients affected with the disease are dead, except one 
whom I occasionally see. A case of improvement and one of cure 
have been reported by Dr. Cheadle, 1 but certainly neither was an 
instance of glosso-labio-laryngeal paralysis, although the face, the 
tongue, and muscles of deglutition, may have been paralyzed. In the 
first of these the disease began with sudden loss of speech, then retro- 
ceded, then returned. There was facial paralysis, incontinence of urine, 
and left hemiplegia. The woodcut, from a photograph, of this case 
does not exhibit a single feature of glosso-labio-laryngeal paralysis. 
The case was probably one of syphilitic basilar meningitis, and the pa- 
tient greatly improved " under iodide of potassium, rest, and nutritious 
food," and was discharged able to swallow with very little difficulty 
and to articulate imperfectly, indeed, but so as to be understood. 

In the second case a complete cure was effected, and, as indicative 
of the character of the disease, I subjoin the essential parts of Dr. 
Cheadle's report : 

A woman, aged forty-two, entered St. Mary's Hospital in Novem- 
ber, 1867. Her speech was so much affected that it was difficult to 

1 " Labio-Glosso-LaryDgeal Paralysis," "St. George's Hospital Reports," vol. v., 18*71, 
p. 123. 



GLOSSO-LABIO-LARYNGEAL PARALYSIS. 487 

make out a word of what she attempted to say ; but, from the state- 
ment of a fellow-servant who accompanied her, and her own subsequent 
statements, the following history was elicited : For some months she 
had suffered from frequent attacks of violent shooting pain in the head, 
accompanied by dimness of vision, and quite unlike any headache she 
ever felt before. With this exception, she had remained in good health 
till a few days before she applied for medical aid, when she was sud- 
denly seized, while sitting in a chair in the daytime, with total loss of 
speech and paralysis of the right side. Her face was drawn, the right 
arm and leg utterly useless, and she found herself only able to utter 
inarticulate sounds; there was no loss of consciousness, or it was so tran- 
sitory as to escape observation. The use of the leg was fully regained 
in about a week ; but the arm remained weak for a considerable time. 
For two days speech was so far abolished that she could only utter 
inarticulate sounds. 

When fully examined several weeks after the attack, it was found 
that she could walk perfectly well, but that the arm was weak and sen- 
sation slightly impaired. Her speech was thick, indistinct, and nasal, 
and she was not able to protrude the tongue fully. The condition of 
the lingual, palatal, and facial nerves was not accurately ascertained. 
She complained of severe shooting pains in the head, and of extreme 
drowsiness. 

She had had four still-born children ; and an eruption, which she 
said was very much like small-pox, made its appearance shortly after 
her first confinement. 

She took small doses of iodide of potassium, but there was no im- 
provement. Mercury was also given, without good result. She then 
came to the hospital. Articulation was still very indistinct; she spoke 
as one very drunk, and was quite unintelligible. In reply to questions 
addressed to her, she had uttered meaningless sounds. 

The treatment was continued, and she gradually improved, so that at 
last she spoke with perfect fluency and clear articulation. 

No one, who has ever seen and studied a single case of glosso-labio- 
laryngeal paralysis, could mistake this case of Dr. Cheadle's for one of 
the disease described by Duchenne. It was probably a case of syphi- 
litic cerebral disease like the first, and like it recovery took place under 
anti-syphilitic treatment. Ameliorations may certainly be produced, 
but probably no cure. The average duration of the disease is about 
two years. 

Morbid Anatomy and Pathology. — Previous to the very recent re- 
searches which have given us a clear insight into the morbid anatomy 
of glosso-labio-laryngeal paralysis, the lesions, detected by several ob- 
servers, were atrophy of the roots of the hypoglossal, facial, spinal 
accessory, and pneumogastric nerves. But late investigations have 



488 DISEASES OF THE SPINAL CORD. 

shown that the lesions of the nerve-roots are secondary to others more 
central in their situation. 

It has already been shown, in this chapter, that the morbid process 
in certain diseases consists of atrophy and disappearance of nerve-cells 
forming the nuclei of origin of certain nerves. Very minute examina- 
tions, made in the cases of persons dying of the disease under notice, 
show very clearly that it also consists of atrophy and disappearance of 
nerve-cells. 

Thus, in the case cited from Charcot, 1 the tongue had preserved its 
former thickness and normal dimensions, but the patient could not ar- 
ticulate, and was obliged to express herself by signs. Intelligence 
was perfect. There was some atrophy of the arms. 

The post-mortem examination showed that the extrinsic muscles of 
the tongue, and those of the supra- and sub-hyoidean regions, were of 
normal appearance and condition. The intrinsic muscles were pale 
and of diminished hardness. 

The laryngeal muscles were healthy, except the posterior crico- 
arytenoid and crico-thyroideus, and presented here and there a yellow 
coloration. 

The muscles of the pharynx had undergone no appreciable altera- 
tion. The muscular coat of the oesophagus appeared to be of normal 
consistence and color. 

In the spinal cord the alterations were confined to the anterior 
horns of gray matter, and to the proper nerve-elements, the neuroglia 
being healthy. The abnormal condition consisted in a disappearance 
of nerve-cells. 

In the bulbar region it was noticed that the nucleus of the hypo- 
glossal presented very pronounced alterations, which here, as below, 
related exclusively to the nerve-cells. The neuroglia was intact. Many 
of the cells were in a state of pigmentary degeneration. The group 
of cells, considered by Lockhart Clarke to be the inferior nucleus of 
the facial, were smaller, and less in number than in the normal state. 
The other cells constituting the nucleus of the facial were in like condi- 
tion. Similar changes were observed in the cells in relation with the 
filaments of origin of the spinal accessory and the pneumogastric nerves. 

In the case which Duchenne 2 has made the basis of some original 
views on the subject of atrophy of nerve-cells, and to which reference 
has already been made, it was found that the cells constituting the 
nuclei of origin of the hypoglossal, the facial, the spinal accessory, and 
the pneumogastric, had become — those that remained — affected with 

1 " Note sur un cas de paralysie glosso-laryngee suivi d'autopsie," Archives de physt- 
ologie, tome iii., 18*70, p. 247. 

2 "De l'atrophie aigue et chronique des cellules nerveuses de la moelle et du bulbe 
rachidienne, a propos d'un observation de paralysie glosso-labio-laryngee," par Du 
cbenne (de Boulogne) et Joffroy, Archives de physiologie, No. 4, 1870. 



GLOSSO-LABIO-LARYNGEAL PARALYSIS. 489 

pigmentary degeneration, and were atrophied, while many had disap- 
peared altogether. 

Among the earliest properly conducted examinations of the medulla 
oblongata is that made by Dr. E. R. Hun, 1 of Albany, in a case which 
appears to have been a typical one of glosso-labio-laryngeal paralysis. 
Sections made from the medulla oblongata showed disappearance of the 
nerve -cells and hyperplasia of the neuroglia in that part where were 
situated the nuclei of origin of the facial and hypoglossal nerves. The 
cells that remained had, in many cases, lost their radiating processes, 
and were in a state of pigmentary degeneration. 

In this case there were in addition symptoms indicating the existence 
of secondary amyotrophic lateral spinal sclerosis, as described by Bou- 
chard and Charcot, and the lateral columns of the cord were found scle- 
rosed. 

It may, therefore, be considered as satisfactorily determined that 
the essential lesion in glosso-labio-laryngeal paralysis is found in the 
medulla oblongata and upper part of the spinal cord, and that it con- 
sists of atrophy and disappearance of certain nerve-cells constituting 
the nuclei of origin of the hypoglossal, the facial, the spinal accessory, 
and the pneumogastric nerves. 

But we are not on that account to disregard the fact that phenomena 
similar to those of glosso-labio-laryngeal paralysis may exist, and as the 
result of very different lesions of the medulla oblongata, or even of no 
discernible morbid condition of that organ. Thus in a case reported 
by Dumesnil a — in which there was paralysis of the tongue, the lips, and 
the veil of the palate, together with atrophy of the muscles of one of 
the upper extremities — the hypoglossal, facial, and spinal accessory 
nerves were found atrophied. No thorough microscopical examination 
was made of the medulla oblongata, and hence such lesions as those 
described by Charcot and Duchenne were not detected. But, whether 
they were present or not, it is undoubtedly true that eccentric lesions 
of these nerves would cause paralysis of the parts involved in glosso- 
labio-laryngeal paralysis. 

Trousseau 3 has described three cases in which post-mortem examina- 
tions were made. In one of these, the results were negative from in- 
completeness of the investigation ; in the second, the roots of the hypo- 
glossal nerve were atrophied, and the medulla oblongata was harder 
than was normal ; and, in the third, the roots of the hypoglossal and 
spinal accessory were in like condition. 

In all of these cases no proper microscopical examination was made 
of the medulla oblongata, and consequently we are without information 
as to the exact condition of that organ. But we can remark of these 

1 " Labio-Glosso-Laryngeal Paralysis," American Journal of Insanity, 1871, p. 194. 

2 Gazette hebdomadaire, Juin, 1859, p. 390. 

3 " Lectures on Clinical Medicine," Bazire's translation, 1866, p. 117, ei sea. 



490 DISEASES OF THE SPINAL CORD. 

cases, as of DumesniPs, that they only show that paralysis may be 
produced by lesions of the nerves, a fact which required no further 
demonstration than it had already received many centuries ago. It 
scarcely, however, admits of a doubt that the atrophy of the nerves 
was the result of central disease, and that this disease was situated in 
the medulla oblongata. 

In Dr. Wilks's 1 case, the roots of the hypoglossal and spinal acces- 
sory nerves were found atrophied, and the medulla oblongata was evi- 
dently the seat of serious disease, but no examination as to the cell- 
lesions was made, nor indeed was it possible then, before the researches 
of Lockhart Clarke, to make such an examination. 

Voisin 2 reports the case of a patient aged seventy-seven, who en- 
tered the Salp&triere, and who soon after admission suddenly lost her 
speech. Gradually, however, she reacquired the power, though she 
had forgotten some words. After remaining three months in the hos- 
pital, she again, after a violent fit of excitement, was deprived of 
speech, and also lost the power to purse up the lips and to raise the 
tongue. The mastication and deglutition of solid substances were 
impossible, the saliva flowed from the mouth, the uvula was immova- 
ble, the inspiration rattling, and the respiration generally difficult. Taste 
and sight extinguished. The glottis was unfortunately not examined. 
The mind was unimpaired, and there was no paralysis of the limbs. 
The patient had to be nourished through an oesophageal tube. She 
died suddenly after the last attack. 

Now, although this is called by Voisin a case of glosso-pharyngo- 
labial paralysis, a title which he uses as synonymous with glosso-labio- 
laryngeal paralysis, it is very evidently not the affection originating in 
the nuclei of the bulbar nerves, and progressing slowly but without in- 
termission to a fatal termination. It is of the same character as the 
cases cited from Dr. Cheadle, and would not be referred to here but foi 
the fact that a post-mortem examination was made. The results were 
as follows : 

There was a small yellow focus of softening at the external part of 
the left lenticular ganglion, which extended to the island of Reil. To 
this circumstance the reporter attributes the amnesic aphasia. 

At the upper and lower surfaces of the two lesser cerebral hemi- 
spheres, just beneath the connecting arm of each, were discovered two 
tumors which appeared to be epithelioma of the arachnoid. The left 
tumor, of the size of a walnut, reached to the medulla oblongata, in such 
a manner that the auditory, facial, hypoglossal, and spinal accessory 
and glossopharyngeal nerves were compressed. These nerves were by 
one-half slenderer than those of the right side. The facial was soft- 

1 " Guy's Hospital Reports," vol. xv., p. 1. 

2 Annates medico-psychologiques, January, 1871, analyzed in the Journal of Psycho* 
leffical Medicine^ New York, vol. v., 1871, p. 816. 



GLOSSO-LABIO-LARYNGEAL PARALYSIS. 491 

ened. The tumor on the right side was of smaller circumference, and 
did not extend to the medulla oblongata. 

Neither the medulla oblongata nor the pons was sclerotic. 

No microscopic examination of the medulla was made, and there- 
fore nothing can be inferred relative to the state of the nerve nuclei. 

In a case in which I had the opportunity of making a post-mortem 
examination, there was also paralysis of the tongue, the lips, and the 
pharynx, but the associated phenomena were not such as to warrant the 
disease being designated as an inflammation of the anterior tract of 
gray matter, causing glosso-labio-laryngeal paralysis. The patient was 
an elderly gentleman of this city, who had suffered from paralysis of 
the lower extremities, and to a less extent of the arms, for several years. 
This condition had been preceded by several seizures not involving loss 
of consciousness, but mainly characterized by deprivation of speech, 
irregular respiration and circulation, and vomiting. 

When I first saw him there was defective articulation, the tongue 
could only be slightly moved, and there was partial paralysis of both 
sides of the face. The function of deglutition was very much impaired. 
Solids could not be swallowed at all, and liquids escaped through the 
nostrils. The saliva ran in streams from the mouth. 

But the most marked disturbance was in the respiration and the 
action of the heart, both of which were exceedingly irregular, the latter 
intermitting frequently, and generally not skipping a single beat, but 
two or three at once. His mind was unimpaired. 

I predicted his death in a few days, for, from the history of the case 
as well as from the existing phenomena, I was convinced that the nu- 
cleus of the pneumogastric was involved with that of the hypoglossal, 
facial, and spinal accessory of both sides, and that the disease was ad- 
vancing. He died within a week, and a post-mortem examination was 
allowed. 

The brain was apparently healthy throughout, except that the pons 
Varolii and medulla oblongata were in a state of extreme softening. 
These were removed, together with the vertebral arteries as far down as 
the lower border of the anterior pyramids, and with the basilar and its 
transverse branches. The coats of the basilar were thickened, and the 
lumen of the vessels almost entirely obliterated. The two lower trans- 
verse branches on either side were entirely closed by dense fibrous clots, 
presenting all the appearance of thrombi. The left vertebral artery was 
also diseased and closed by an old clot extending about an inch and a 
quarter from its junction with tfte vertebral of the opposite side. The 
tissue of the pons Varolii and medulla oblongata was so much softened 
as not to admit of hardening in chromic acid. The parts were placed in 
absolute alcohol and examined in a few days, but the degeneration was 
so thorough that nothing more could be ascertained than the fact of the 
almost complete destruction of the nerve-elements. 



492 DISEASES OF THE SPINAL CORD. 

In this case, although the symptoms were in some respects similar 
to those of glosso-labio-laryngeal paralysis, yet it is very obvious that 
the affection was not this disease. The paralysis of the extremities and 
the paroxysms of speechlessness were indicative of a more extensive 
and different lesion, and the post-mortem examination showed that the 
original trouble was altogether extrinsic. The bulb was invaded from 
the exterior instead of from the interior. 

It would be just as proper to designate the case described on page 
486, under the head of spinal paralysis of adults, one of glosso-labio- 
laryngeal paralysis on account of the bulbar symptoms, as to consider 
the one just described and others of its class as coming under this cate- 
gory. That ischaemia of the medulla oblongata, however, will give rise 
to the symptoms of glosso-labio-laryngeal paralysis is not only evident 
from pathological considerations, but also from recent anatomical re- 
searches. Thus Duret 1 concludes, as the results of his investigations, 
that, when a clot is situated in one of the vertebral arteries, it interrupts 
the circulation in the anterior spinal artery, and consequently in the 
median arteries which arise from it ; that is to say in the arteries which 
supply the nuclei of the spinal accessory, the hypoglossal and the infe- 
rior root of the facial. It therefore causes the development of the 
symptoms of glosso-labio-laryngeal paralysis. When the clot occupies 
the inferior part of the basilar trunk, it cuts off the blood from the sub- 
protuberantial branches which supply the nucleus of the pneumogastric. 
and sudden or at least rapid death is the consequence. 

In regard to the character of the morbid process by which the de- 
generation, atrophy, and disappearance of the nerve-cells are effected, 
Leyden 2 considers it to be a myelitis, and this is probably the correct 
view. In this light, therefore, it does not differ essentially from the 
corresponding process which, situated lower down in the cord, produces 
infantile spinal paralysis and the spinal paralysis of adults. 

Wachsmuth, 3 who was among the first to study the subject, argued, 
from a consideration of the symptoms, that the affection in question 
was characterized by destruction of the nerve-cells in the floor of the 
fourth ventricle, and that the degeneration of the nerve-roots was a 
secondary process. As we have seen, it was reserved for Charcot and 
Duchenne and Joffroy to establish the correctness of this opinion by 
post-mortem investigations. 

As to the acute glosso-labio-laryngeal paralysis, or acute bulbar pa- 
ralysis, as it has been called by Leyden i and other German writers, 

1 " Sur la distribution des arteres nouricieres du bulbe rachidien," Archives de physio- 
togie, 1873, p. 97. 

2 " Ueber progressive Bulbarparalyse," Archiv fur Psychiatrie und Nervenkranlch.ei 
fen, B. ii. und iii., 1870-'73. 

3 "TTeber progressive Bulbai paralyse und diplegia facialis," Dorpat, 1861. 
« " Klinik der Nerrenkrankheiten," Berlin, 1875, B. ii., p. 15*7. 



GLOSSO-LABIO-LARYNGEAL PARALYSIS. 493 

and the " glosso-labio-laryngeal paralysis of apoplectic form " of Jof- 
froy ' and of Proust, 2 cases such, as those described by these authors, 
are to be considered in the light of the foregoing remarks, and not as 
instances of inflammation of the anterior tract of gray matter leading 
to destruction of the motor cells. 

In regard to the coexistence of glosso-labio-laryngeal paraly- 
sis with certain affections of the cord, characterized by atrophy 
of the muscles, the point will be fully considered under the heads 
of Progressive Muscular Atrophy and Amyotrophic Lateral Spinal 
Sclerosis. 

One other point : What is the essential physiological character 
of the cells which have become degenerated, atrophied, and many 
of which have disappeared ! In infantile spinal paralysis, and in the 
spinal paralysis of adults, we have seen reason to think that the cells 
which are the seat of disease are both motor and trophic, for these 
affections are evidenced by paralysis and atrophy. But in the disease 
under consideration there is seldom atrophy, which, when it does occur, 
is to my mind an evidence of a complication of glosso-labio-laryngeal pa- 
ralysis with progressive muscular atrophy — a disease to be considered 
subsequently — and not merely to an extension of the morbid process 
from the nerve nuclei to the nerves themselves, which is the view gen- 
erally held by neurologists ; for glosso-labio-laryngeal paralysis is not 
a disease in which the muscles are defectively nourished, but one the 
essential feature of which is paralysis. It is reasonable, therefore, to 
suppose, with Duchenne, that the nerve-cells which have become dis- 
eased are motor cells. 

Onimus 3 asserts that there is no evidence to show that glosso-labio- 
laryngeal paralysis ever exists without atrophy of the tongue, but this 
is directly at variance with the experience of other observers and alto- 
gether inconsistent with my own investigations. That there is a form 
of progressive atrophy affecting the tongue is very certain, but it is 
not glosso-labio-laryngeal paralysis. As regards the relation of the 
symptoms observed to the known distribution and functions of the 
nerves concerned, there is no difficulty. The affection of the hypo- 
glossal causes the paralysis of the tongue, and the consequent impos- 
sibility of articulation, and of moving the food in the mouth ; the 
implication of the facial accounts for the paralysis of the lips and the 
muscles of the veil of the palate, and the resultant impossibility of 
sounding certain letters, and of swallowing ; the extension to the spinal 
accessory explains the paralysis of the larynx, the loss of phonation, 
and the feebleness of respiration ; and death, when it takes place as it 

1 "Sur un cas de paralysie labio-glosso-laryngee a forme apoplectique d'origine bul- 
baire," Gazette Medicate, 1872, No. 41. 

2 "Sur la paralysie labio-glosso-laryngee," Gazette des Hopitaux, 1870. 

3 " Paralysie labio-glosso-laryngee," Gazette des Hopitaux, September 30, 1872. 



494 DISEASES OF TIIE SPINAL CORD. 

sometimes does from the sudden stoppage of the heart's action, is due 
to the implication of the pneumogastric, to which cause other paralyses 
of the muscles of animal life are to be ascribed, 

Treatment. — From what was said relative to the prognosis, it will 
have been perceived that there is not much to expect from treatment, 
I have, however, occasionally produced good results which have, for a, 
time at least, rendered the condition of the patient more tolerable. Thus, 
the first patient who came under my care was much relieved by fara- 
dization of the paralyzed muscles. He improved very much in his ability 
to swallow, and in power over his tongue and lips. These ameliorations 
were not permanent. In the case of the gentleman from Pittsburg, as 
well as in all the other cases but one, similar treatment, together with the 
use of the primary galvanic current and phosphorus, was without the least 
effect. In this latter case some benefit was apparently produced for a 
time. The course of the disease was certainly less rapid than before 
treatment was begun, but it nevertheless slowly advanced to a fatal 
termination. 

3. Inflammation of the Trophic Cells. 

In admitting the existence of trophic cells in the anterior tract of 
gray matter of the spinal cord, I have been influenced by what I con- 
sider to be the weight of evidence. The fact is one which, in the pres- 
ent state of our knowledge, is not capable of absolute demonstration; 
but the subject is of such a character as scarcely to require proof of 
that nature. The inference for their existence is as strong as that 
which we draw relative to the presence in the spinal cord of cells spe- 
cially in relation with the functions of motion and of sensation. As we 
have seen, there are affections of the cord in which there are both pa- 
ralysis and atrophy. In such cases, we have good reason for concluding 
that the cells which are in nervous connection with the paralyzed and 
atrophied muscles have both motor and nutrient properties. This de- 
duction is strengthened by the fact that there is another disease which 
is characterized by the existence of paralysis without atrophy, and 
which post-mortem examination shows to be due to the degeneration, 
under the influence of inflammation, of certain cells situated in the me- 
dulla oblongata and in direct anatomical relation with the nerves sup- 
plying the paralyzed parts. These cells, there is every reason to believe, 
are exclusively motor. 

We have now to consider the affections of the spinal cord, and still 
of the anterior tract of gray matter, which are manifested by atrophy 
without paralysis, except in so far as an atrophied muscle necessarily 
possesses less power than one which is of full size. 

Two such affections have been recognized, or, rather, one — progres- 
sive muscular atrophy — has been regarded as a disease of the anterior 



PROGRESSIVE MUSCULAR ATROPHY. 495 

tract of gray matter of the spinal cord by the great weight of author- 
ity ; while the other — facial atrophy — is now for the first time, so far 
as I am aware, placed in the same category. That this is warranted 
by the clinical histories of the cases I shall have to adduce, will, I 
think, be apparent to the reader, 

a. Progressive Muscular Atrophy. 

Although cases of progressive muscular atrophy were noticed by 
the older writers, the first systematic account of the disease was given 
by Duchenne, 1 in 1849. In 1850 M. Aran 2 published his memoir, in 
which he gives the histories of eleven cases; and three years subse- 
quently Cruveilhier 3 read a paper on the same subject before the 
Academie de Medecine. About the same time other memoirs were 
published on the subject. 

But, although Cruveilhier was not the first to write upon the affec- 
tion in question, he was the first to describe it, and Duchenne and Aran 
were aware that he had done so in his lectures for several years. The 
disease is therefore sometimes called Cruveilhier's atrophy. 

Symptoms. — The first symptom observed in the majority of cases is 
loss of strength and dexterity in certain muscles of the body. If these 
are in the lower extremities, the patient finds that he tires in walking 
sooner than he used to do. If in the upper extremities, he experiences 
weakness in the shoulder, arm, or hand, according to the muscles af- 
fected. 

Soon afterward pains simulating those of neuralgia are felt in the 
paretic muscles. These are not probably due to the central lesion, but 
are the result of muscular fatigue which is itself due to the incipient 
atrophy which even at this stage exists. 

In the majority of cases — according to my experience in all — fibril- 
lary contractions are perceived. Thus, of fifty-two cases of progressive 
muscular atrophy which have been under my charge during the past 
ten years, these contractions formed a prominent feature in every one. 
They consist of slight twitchings of separate bundles of muscular fibres, 
and give the sensation of something alive being under the skin. They 
can often be seen, especially when superficial fibres are involved, and 
they are generally the avant courriers indicating the extension of the 
disorder. Even if for a time they are not noticed they can always be 
excited by a smart tap on the atrophied muscle, except in the latter 
stages of the disease. 

1 "Atropine niusculaire avec transformation graisseuse," "Memoires del'academie dea 
sciences," 1849. 

2 " Recherches sur une maladie non encore decrite du systeme musculaire," Archives 
Generate de Medecine, 1850. 

3 " Sur la paralysie musculaire progressive atrophique," Archives Generate de Medecint. 
1853. 



496 



DISEASES OF THE SPIXAL CORD. 



The loss of strength attracts the attention of the patient to his 
limbs, and then he finds that the weakness is accompanied by atrophy. 
If, as is usually the case, the disease begins in one of the upper ex- 
tremities, the thenar and hypothenar eminences very commonly give 
the first evidence of atrophy. The ball of the thumb disappears, and 
the muscles filling the space between the first and second metacarpal 
bones — the adductor pollicis and the first interosseous — likewise shrink 
away. The whole outline of the metacarpal bone of the thumb can 
thus, very soon, easily be made out. 

The ball of the thumb is often the starting-point of the disease, 
and, when this is not the case, it generally becomes involved at some 
time or other in the course of the affection. Of the fifty-two cases 
occurring in my experience, the disease appeared first in the ball of 
the thumb in nineteen, and eventually attacked this part in twenty- 
one others. The upper extremities were the original seat of the dis- 
ease in forty-two cases, the trunk in four, and the lower extremities 
in six. Whether the affection begins in an upper or lower extremity, 
the tendency is for the opposite member to be next involved. 

The physiognomy of progressive muscular atrophy is very striking, 
particularly when the face or the hand is its seat. One very well- 
marked case of the former has 
FlG - 51 - come under my observation, and 

it can readily be understood that 
the change effected by the dis- 
appearance of the facial muscles 
must be very evident. In the 
case in question — represented in 
Fig. 51) — the right side of the 
face was strikingly involved, and 
the muscles of the neck and 
shoulder on the same side were 
affected to a marked degree. In 
jg§ :: 4 the hand, the atrophy of the mus- 

^"""' r '' ~. cles which, give this member its 

>; #^: \ plumpness, and enable it to per- 

form the complex movements 
of which the fingers are capable, 
causes appearances which are easily recognizable. By the disappear- 
ance of the thenar eminence, the skin over it hangs in loose folds, the 
thumb falls by its own weight, and cannot be brought into apposition 
with the index-finger — the palm of the hand is hollowed out, and the 
metacarpal bones can be distinctly seen and felt. 

In the forearm, the situation of the disease can be readily ascer- 
tained by the flattening produced by the disappearance of the affected 
muscles, and in the arm and shoulder the effects of the disease are still 




PROGRESSIVE MUSCULAR ATROPHY. 497 

more evident. In three cases, the disease had begun in the right del- 
toid, and had not extended beyond this muscle when the patients came 
under my charge. In all, the shoulder was flattened, and the head of 
the humerus and the acromion process could be distinctly seen. In 
another case it was limited to the trapezius and scapular muscles of 
both sides. 

In the lower extremity, the changes in the foot are not so remark- 
able as the corresponding ones in the hand, but the effects produced by 
the atrophy of the peroneal muscles, the tibialis anticus, and those 
forming the calf of the leg, are very striking, In the one case, the 
foot drops, and the patient is obliged to bend the knee to a greater ex- 
tent than usual in order to make the toes clear the ground ; in the 
other, the heel cannot be raised, and the ankle gives way with the 
weight of the body. When the muscles on the anterior face of the leg 
are in process of destruction, the forms of the tibia and fibula can be 
distinguished, and the space between the two bones is unfilled. The 
disappearance of the calf makes the posterior aspect of the leg 
flat. 

In the thighs the atrophy is also readily perceived, and modifies very 
materially the gait of the patient. When the extensors on the anterior 
face of the thigh are involved, the leg cannot be thrown forward; when 
the flexors are the seat, the leg cannot be raised, and the whole mem- 
ber has to be lifted up by the action of the flexors of the thigh on the 
pelvis. 

A singular circumstance connected with the disease is the tendency 
exhibited for a single muscle or a group of muscles to escape atrophy, 
while all the surrounding ones are profoundly affected. Thus, as in a 
case reported by Duchenne, 1 all the muscles of the hand and forearm 
were completely atrophied with the exception of the supinator longus, 
which remained in its normal condition. This is well shown in the cut 
(Fig. 52) from Duchenne's work. 

Sometimes the atrophy, after destroying a muscle or two, ceases to 
extend. Thus, in a case referred to me by Dr. D. H. Goodwillie, of this 
city, the atrophic process had been spontaneously arrested after com- 
pletely destroying the muscles of the right thenar eminence, and the 
patient had remained for eighteen years entirely free from any active 
manifestations of the disease. 

The temperature of the atrophied muscles is usually several degrees 
below the normal standard. In the case of a gentleman whom I recent- 
ly examined with reference to this point, and whose right hand, fore- 
arm, and arm, are in a state of advanced atrophy, I found, by means of 
Dr. Lombard's instrument, the temperature of that extremity to be 5° 
Fahr. below that of the other. 

1 "De 1' electrisation localisee," troisieme edition, Paris, 1872, p. 606, 

33 



498 



DISEASES OF THE SPINAL CORD. 



Fig. 52. 



The cutaneous capillaries are usually relaxed, and hence the skin 
over the affected parts is discolored by the passive engorgement. 

The electric contractility of the affected muscles diminishes both 
to the faradaic and the galvanic currents in direct ratio to the atrophy 
of muscular substance. As the muscle gradually decreases in volume, 
so the contractions to both forms of current perceptibly fail. When 
the atrophy becomes extreme the faradaic excitability is lost alto- 
gether, but so long as any muscular fibres re- 
main, slight contractions can be obtained 
from the galvanic current. The polar reac- 
tions, in the great majority of cases, remain 
unchanged, but in a few instances the anodal 
closure contraction has been found to be 
equal to, or slightly in excess of, the cathodal 
closure contraction. This is only observed 
in advanced stages of the disease. 

The reflex excitability in the early stages 
appears to be increased, but as the disease 
advances it becomes less and less, and is 
finally altogether lost. Thus, when the fibril- 
lary contractions, which characterize the in- 
itial period, are temporarily absent, they can 
be readily reexcited, as previously mentioned, 
by striking the skin over the affected muscle. 
Besides the paralysis, which it must be 
clearly understood results from the atrophy, 
and is directly proportional to its extent, 
there may be contractions. These, when 
present, are due to the fact that the atrophy 
has not attacked all the muscles of an ex- 
tremity simultaneously, or to a like degree, 
and consequently, the normal antagonism be- 
ing destroyed, distortions take place. When 
these occur in the hand, they produce the 
main en griffe of Ducherine. Of the twenty- 
nine cases occurring in my experience, seven 
only had any distortions. In infantile pa- 
ralysis, which is similar in several respects 
to progressive muscular atrophy, contractions and distortions are much 
more common. 

The pupils are sometimes contracted from the implication of nerve- 
cells in the cilio-spinal region of the cord. This was the case in one or 
both eyes in four of my cases. 

The course of the affection is slow, but in the great majority of cases 
it advances to a fatal termination. Death takes place from the muscles 




PROGRESSIVE MUSCULAR ATROPHY. 



499 



of respiration becoming involved, from exhaustion, or from some inter- 
current affection. Several of my cases have lasted over ten years. 

It is worthy of notice that there is no instance on record of the 
muscles of the eye-ball or the levator palpebral superioris being affected. 

The accompanying woodcut (Fig. 53), from Friedreich, represents 
a patient, Ludwig Bessing, forty-five years old, who certainly presents 

Fig. 53. 




a remarkable example of the disease. Almost all the muscles of the 
body, trunk, and extremities were in a state of extreme atrophy, the 
only exceptions being found in the left forearm. The disease had re- 
mained stationary for many years, during all of which period there 
were strong fibrillary contractions. No hereditary influence could be 
ascertained to exist. 



500 DISEASES OF THE SPINAL CORD. 

MM. Duchenne and Joffroy ' have shown that glosso-labio-laryngeal 
paralysis is sometimes complicated with progressive muscular atrophy, 
and that this latter affection, implicating the muscles of the tongue, 
the lips, and the veil of the palate, has hitherto been confounded with 
the first-named disease. It differs from it, however, in the essential 
fact, which is applicable to the disorder appearing in other parts of 
the body, that the loss of power is not the initial symptom, but results 
directly from the diminution in the size of the muscles. This point 
will be further considered under the head of Diagnosis, when other 
cases similar to that here referred to will be brought forward. 

The progressive muscular atrophy of infants presents some features 
different from those met with in adults. Duchenne, 2 who has elucidated 
this point of the subject, has ascertained that the initial atrophy, in- 
stead of beginning in the upper extremities, as it usually does, or in the 
trunk or lower extremities, as is occasionally the case, starts from cer- 
tain muscles of the face, giving a peculiar expression to the countenance. 
I have never witnessed, to recognize it, a case of progressive muscular 
atrophy in an individual under the age of eight years ; consequently, 
no instance of the infantile form of the disease has come under my 
notice. Duchenne has witnessed fifteen cases, and in each the begin- 
ning of the malady occurred between the ages of five and seven. 

The muscle first to be affected is the orbicularis oris, and, as he 
states, its failure to contract occasions a characteristic thickness of the 
lips. The expansion of the mouth, as in laughing, is then only effect- 
ed by the buccinator and the risorius. Eventually, other muscles of 
the face become involved, and finally the atrophy extends to the supe- 
rior extremities, the trunk, and the lower limbs. 

The accompanying cut (Fig. 54), after Duchenne, represents in pro- 
file the face of a boy thirteen years of age, whose lips had, in infan- 
cy, become thick and pendent, and whose orbicularis oris, levatores 
labii superioris, levatores labii superioris alseque nasi, and the zygo- 
matici, had become atrophied, and, when stimulated by strong faradaic 
currents, gave no response. At the age of twelve the muscles of the 
chest had become affected. In this case, as in one other in Duchenne's 
experience, the disease had been transmitted through the mother, who 
was herself the subject of progressive muscular atrophy. 

Charcot and Marie 3 have described another form of progressive 
muscular atrophy in which the morbid process is first observed in 
the muscles of the foot. This form of the disease has been termed by 
Tooth the "peroneal type." The atrophy may begin either in the 
extensor hallucis longus, the common extensor of the toes, or in one of 
the peronei, and from them extend so as to involve the gastrocnemius 

1 " De l'atrophie aigue et chronique des cellules nerveuses de la moelle et de bulbe 
rachidien," Archives de Physiologie, No. 4, 1870, p. 499. 

* Op. cit., p. 518. 3 Rev. de Med., Paris, 1886. 



PROGRESSIVE MUSCULAR ATROPHY. 



501 



and later on the muscles of the thigh. After several years the dis- 
ease appears in the upper extremities and then runs the usual course. 
There are fibrillary contractions, and the muscles respond feebly but 
accurately to both faradaic and galvanic currents, except in a few 
instances in which degenerative 
reactions are observed. 

I do not see the advisability 
of creating new types of pro- 
gressive muscular atrophy and 
naming them in accordance with 
that part of the body where 
the disease is first manifested. 
Whether the atrophy begins in 
the hand, the face, or the foot, 
it follows a regular and definite 
course, which is nearly identical 
in each instance and undoubted- 
ly originates from a lesion of 
the spinal cord — to be referred 
to later — which, according to its 
situation in the cerebro-spinal 
system, may produce the initial 
atrophy in one part of the body 
or another. 

Causes. — Progressive muscular atrophy is not a disease of old age. 
Only two of my cases were in persons over fifty ; four were between 
forty and fifty, and forty-six were under forty. Of these latter, three 
were between fifteen and twenty, and two between eight and ten. The 
period of life at which it appears to be most common is that extending 
from twenty-five to thirty-five. 

Sex is a strong predisposing cause. All of my cases were in males, 
except one, a lady from Providence, Rhode Island, in whom the face 
and tongue were involved in the morbid process. Roberts J states 
that, of ninety-nine cases, eighty-four were males, and only fifteen 
females. Other authors have noted the greater proclivity of males. 
The difference appears to be due to the greater severity of muscular 
exertion required in many of the occupations of men. 

Hereditary influence is a well-recognized predisposing cause. Two 
of my cases sent to me by Dr. Lincoln, of Washington City, were 
brothers, two others are sons of a prominent manufacturer of this city, 
and fourteen others had relatives affected with the disease. 

But by far the most remarkable history of the hereditary transmis- 
sion of the disease, which has come to my personal knowledge, is con- 
tained in the following account, which constitutes a pamphlet written 
1 "An Essay on Wasting Palsy," London, 1858, p. 135. 




502 DISEASES OF THE SPINAL CORD. 

by one of the unfortunate subjects, and sent to me by Dr. R. F. 
Andrews, of Gardner, Massachusetts. The interest attaching to the 
whole matter, as well as in consideration of the graphic, though homely, 
manner iri which the story is told, will, I am sure, be sufficient apology 
for my quoting the entire pamphlet : 

"muscular ateophy. 

"Among my ancestors and their neighbors this disease was known as the 
' Wetherbee Ail ; ' definitely, it is a wasting or consumption of the muscles. 
Until recently, it has been considered incurable ; the cause is unknown, but gen- 
erally the first intimation the patient has of it is a shock. My opinion is that its 
inception is some time previous, but not noticed. From and ever after the 
shock its progress and character are remarkable, the various symptoms and 
details of which will be seen in the individual cases I shall attempt to describe. 

"I have been unable to trace the history of this disease beyond my great- 
grandfather, Ephraim Wetherbee, and all I know of his history is that he had 
six sons and two daughters, and that he died of the 'Wetherbee Ail.' His son 
Asa experienced a sensation in the calf of both legs, as if struck smartly with a 
whip ; I do not know how long he lived, but he failed from that time; Isaac, 
another son, had the same disease, but I have been unable to learn any partic- 
ulars in his case. Two others, Calvin and Joseph, the latter my grandfather, 
died in South America of diseases prevalent in that country ; I can say nothing 
of the others. Hannah Wetherbee, one of the daughters, I can remember to 
have seen walk feebly and soon after confined to her room nearly helpless, and 
to have seen her coffin-lid screwed on. Sarah married a Mr. Paine ; she had had 
seven children and was in good health ; she was walking on the street and felt 
as if hit in the calf of the leg by a stone, and turned expecting to see the boy 
who threw it, but concluded that was not the case; she lost the spring of her 
toes, as she expressed it, and never walked naturally afterward; she told her 
family, on her arrival home, that she had the ' Wetherbee Ail.' She lived seven 
years, had the best of care and medical treatment; she had two children during 
her sickness, the last a son, after she had become perfectly helpless and only 
nine months previous to her death. She had nine children; one died young, the 
others are living and in good health. I had these particulars from the eldest, 
Sarah Paine, who married Spaulding, and is nearly sixty years of age, has gen- 
erally been in good health, excepting during some three years she suffered from 
nervousness and lost all her strength ; but she recovered and for some twenty 
years has been well. She had a son and daughter who both married; the 
daughter died of consumption of the blood, the son is in good health. Mrs. 
Spaulding names other cases but can give no particulars except that one felt the 
first shock in the foot under the shoe-buckle, such as were worn a hundred years 
ago; another was attacked in the brain and lived but twenty-four hours (I 
should not call that a case of muscular atrophy) ; another requested that an 
examination should be made after his death, which being done showed that all 
the muscles were consumed. 

" Joseph Wetherbee, my grandfather, had a son and daughter ; the daughter. 
Lucy, married a Mr. Pitts ; she had only a son and daughter. The daughter 
lived some twenty years and died of some sudden and severe sickness. The son, 
J. Henry Pitts, is still living and is about forty-three years of age: has suffered 



PROGRESSIVE MUSCULAR ATROPHY. 503 

much from rheumatic fever. Aunt Lucy herself, enjoyed good health till about 
fifty years old, when she died. She believed there was nothing peculiar in the 
so-called ' Wetherbee Ail.' Her last sickness was of an entirely different char- 
acter. 

" I now come to the case of my father. He was of a robust build, had a 
strong constitution and was temperate, drinking no spirits since my remem- 
brance, probably not much before ; used some tobacco at times, and worked 
hard at different trades, as shoemaking, farming, and chair-making. When about 
thirty -nine he remarked that he was growing old fast, and some of the neighbors 
discovered a slight limp in his walk. I was not living at home at that time, and 
do not know much of his condition in the early stages of his sickness. He first 
discovered a weakness in the right thumb, being unable to open his pocket-knife 
in the usual way. The right hand and arm lost strength faster than the left ; 
and, contrarily, the left leg failed the fastest. He thought the direct cause of his 
lameness to be over-exertion in harvesting a crop of meadow-hay, in August or 
September, 1844. He continued to labor about a year. The progress of the 
disease was rapid ; he suffered somewhat from painful muscular contractions or 
cramps, otherwise he had but little pain. The larger muscles of the arms and 
legs became soft and flabby, and diminished in size. In November, 1845, he cut 
his fingers in the shop, went home and never entered the shop again. He got 
about the house with crutches several month?, comfortably. During the follow- 
ing winter he had rheumatic fever. In the summer of 1846 he became nearly 
helpless. Mother and myself lifted him to his feet, and to and from his bed and 
chair. The kidneys were also affected, and the lungs were very weak. So he 
wasted in flesh and strength, and died on the 10th of October, 1846, a little more 
than two years after the hard work in the meadow. 

" I can say no more of the above cases, except that the persons were native- 
born Americans. Mrs. Spaulding thinks we descended from the English. I do 
not learn that there was dissipation in any branch of the family. There are 
branches of the family in which nothing of the kind appears ; there is nothing 
of it in the Wetherbees in Scotland. Mrs. Spaulding thinks the disease was in 
the family previous to the time of my great-grandfather. 

" I was born on July 23, 1831, in Westminster, Massachusetts. At the age 
of five I was thrown from a wagon and got a scalp-mark from the horseshoe. 
At the age of six I remember an aching head and discharge at the ear ; at seven 
or eight a bad cold, with soreness of chest, a cough and hot gin-sling, none of 
which were in the least agreeable. When eleven I was badly poisoned with ivy, 
although before that I had handled it with impunity; at fourteen another cold 
and affected chest and lungs, with ulcers, or something like, in the head. 

" From this time to the age of twenty-one I had some sick-headache ; got 
sick three times from trying to paint outside work, got poisoned with ivy and 
dog-wood, but did not lose many meals or much sleep. I worked at chair- 
making and had no lack of out-door exercise. As I have spoken of shocks be- 
ing felt by some of the above-named persons, I am reminded that I felt one on a 
day in the summer that I was sixteen ; I felt as if struck with a piece of board 
on the left shoulder, head, and neck. I looked around for the cause but saw no 
one ; I was not hit nor hurt ; have felt something similar since, but as nothing 
came of I thought no more about it. At twenty-one I had a lame stomach, 
partly from w T ork and from getting a blow in the breast. One plaster set that 
all right, and I have had nothing of it since. 



504 DISEASES OF THE SPINAL CORD. 

" In January, 1855, I had lameness in the right wrist and hand, attributing 
it to a slight, and at the time unnoticed, sprain by rolling logs. I had much 
pain and trouble during three or four years ; many times I could scarcely write, 
and came to use the hammer and saw with the left hand. It is useless to name 
the various modes of treatment, as time only seemed, effectual in restoring the 
parts to nearly their natural condition. In December, 1855, I had a severe cold, 
affected lungs and head ; had discharges at the ear, but kept the house for a few 
days and recovered. Early in the summer of 1857 I had poor appetite and no 
ambition, headache, and slight night-sweats. I gave up work early in August, 
put myself under a doctor's care, improving much iD two months, and before 
winter gained my usual health. Early in the spring of 1858 I had palpitation 
of the heart, caused by eating new maple-sugar ; have been subject to it ever 
since, at intervals from a week to a year and a half, always brought on by drink- 
ing water or ale, or eating an apple. I felt somewhat weak during their con- 
tinuance, but usually kept at what I happened to be doing, though they lasted from 
six to thirty-six hours. Two or three years following I had two sharp stitches 
in the back, by lifting a slight weight, resulting in a lame back for a season. 

" In August, 1862, I enlisted in the army and soon went to Virginia ; had but 
little difficulty in getting accustomed to camp-life and climate. I had no occasion 
to answer surgeon's call until the following winter, when I got cold, being on 
guard night and day during Burnside's so-called 'mud march,' resulting in pain 
in the bowels and diarrhoea, but that all wore away in a month or two. During 
May, 1863, while in camp at "Washington, I took a cold which troubled me till 
after the battle of Gettysburg, when I had my left thigh fractured by a spent 
grape-shot. The fracture, only a simple diagonal, was never set, the bone unit- 
ing in its own way and time, consequently the left leg is about two inches short- 
er than the other, and crooked. 

" In 1864 I received my discharge. I walked with a cane the following sum- 
mer, then gave it up ; experienced no difficulty excepting the limp resulting from 
the shortness of the ]eg. During the year 1865 I was engaged in work which 
kept me on my feet. I frequently walked two miles, out and back, but experi- 
enced more fatigue than in previous years. In May, 1866, I went to Chicago, 
and engaged in sedentary occupation ; had about seven-eighths of a mile to walk 
to and from work. I usually walked rapidly, many times beating the horse-cars. 
In July, 1867, I went to Pennsylvania and engaged in chair-making; on my feet 
all of the time, and some of the time standing still at a machine ; also walked 
much over the rough hilly roads in that country. I was there upward of three 
years; during the time I had two or three attacks of lame back, also of piles. 
When taking an armful of stock from the floor I found it convenient to keep a 
stick in the right hand to assist in rising. In a letter to my brother I remarked 
I felt that I was getting old. As I was then about the same age my father was 
when he made the same remark, the coincidence is remarkable. 

"Late in 1869 or early in 1870, I noticed a fibrillous contraction just above 
the right knee, about half-way from the anterior to the inside. It is a tremu- 
lous twitching of the muscles, which is seen in the muscles of slaughtered ani 
mals after the skin is taken off. It is painless but somewhat disagreeable, and 
more noticeable after retiring. In two or three days it was gone. I was at 
that time standing at a lathe during the day, and walking rapidly morning, noon, 
and night. In November, 1870, I came to Gardner, where my employment was 
such that I had to stand stiller than ever. I was advised to sit on a stool part 



PROGRESSIVE MUSCULAB A.TROPE 

of the time, but I was not inclined to do so. I walked rapidly to and from the 
shop, each trip requiring about twelve minutes, lour trips a day up hill and 
down. In February, 1871, I felt a general lameness or muscular sor 
over-exertion, loss of sleep, and taking oold. 1 bad bad -u- i. 
most persona have the same. About the 20th or 25th of March I noticed for 

the first time that I Went up-stairs with much dillicult y, the trouble seeming to 
bo in the right thigh. On the 26th of March 1 walked to We-tnnnster, a 

ace of five miles, and back. I felt generally fatigued, bn< noticed do par- 
ticular lameness. That was the last foot-journey of any d took. 

Twice in April I quiokened my paoe to pass some persons on the sidewalk, and 

felt B quiok, painful sensation in the anterior portion Of tbe right thigh. A few 

days subsequent to this there was an alarm of lire about twelve o'clock. 1 
started to run, but gave it up after a few steps, and have not tried to run since. 

"I was a little anxious about all this, but did not Buspeot any permanent 

lameness existed. I cannot say when tbe thought of the ' Wetherbee Ail ' came 
into my mind. On May 11th, as I was going of an errand in the morning, I 
stopped to throw a stone at a small hawk in an apple-tree, but fell myself, and 
the hawk Hew away. Twice soon after I fell on throwing a Btone. About this 
time I had severe cramps in the right thigh, and have the impression that there 
were cramps in the right thumb. I consulted a doctor about this time, and be- 
gun a regular course of treatment. The 1st of June I gave np going home for 
my dinner, and sat on a stool much of the time while at work. I still walked 
comfortably, but could not raise my weight up an ordinary step, and I had to 
be careful that the knee set at every step, or it would cripple and let me down. 
The reader will notice that the leg which was not broken failed; as it was some 
two inches longer than the other, it had to bear the greater burden, and, in go- 
ing up-hill or up-stairs, virtually had to raise my weight two inches higher at 
every step than the broken leg. The tremulous twitching was very marked 
during this time, and occasional painful cramps. I continued to lose strength 
all summer, and was obliged to give up some kinds of work. 

"September 1st, I found that the right thigh measured only sixteen inches, 
while the left measured nineteen. I used a cane at this time and found it of 
much service. At this time I rode to and from the shop. About the 1st of 
November I found the left leg began to fail. The 1st of January, 1872, I found 
much difficulty in walking only a short distance. I gave up work and went to 
the Massachusetts General Hospital for five weeks; but no effect of the treat- 
ment was apparent ; think the right thigh had decreased to fourteen and one- 
half inches in one year. There was but very little strength in the right leg, the 
muscle of the thigh was very flabby, and the heat was lower than in the other leg. 
I resumed my occupation in February. The fibrillous contractions and painful 
cramps had by this time nearly ceased in the right leg, but were visible in the 
left ; also noticed weakness in the right thumb, especially when cold, and could 
not hold a carpenter's pencil in the usual way. I cannot state the number of 
times that I fell ; I continued to ride to my work. Late in May I could bear no 
weight on my left toes. Meantime I had bandaged my right foot and leg to the 
knee, on account of swelling. On the 27th of July I was thrown from a car- 
riage, the immediate result of which was a general muscular soreness, particu- 
larly in the left foot and arms. 

" From this time the progress of the disease was marked and rapid, espe- 
cially in the ball of the right thumb and the left thigh. I now found it unsafe to 



506 DISEASES OF THE SPINAL CORD. 

step without a cane, or out of the reach of something permanent. As the cold 
weather came on, I had to change my job for a lighter one in a warmer place. 
I gave up walking in the shop, used a wheel-chair, and was during the fall put 
into a buggy by a strong man. I continued to work through December, except- 
ing some of the coldest days, but on the last afternoon of the year 1872 I fell 
and severely sprained the left knee ; was obliged to quit work, and have done 
nothing since. 

11 At no time, since I first felt the lameness in the right thigh, have I been 
able to say with truth that I was a little better, or even about the same ; but 
that I was not so strong as I was a month previous. This disease never stands 
still. I will close this sketch by saying, that at this writing I cannot stand 
alone, have no control of the right leg whatever, and cannot move the toes. 
The left is very weak ; both feet, and the legs below the knee, are somewhat 
cold most of the time. I dress without assistance. My arms are not strong 
enough to raise my weight to my feet ; have not strength to cough or sneeze 
with any force. Have a fair appetite and sleep well. It is probable that nearly 
every muscle in the system is affected, as I have felt the cramps and tremulous 
contractions in nearly every part. There is no loss of sensation in any part. 
The large muscles of the right thumb are much wasted, the whole hand has a 
bony appearance, and the third finger droops. Sometimes I cannot pick up a 
pin, and my writing is scarcely legible. I gave up all treatment six months 
ago, as I could never see any difference in the progress of the disease while 
under treatment and while not. 

" One theory is, that this disease is not inherited by the descendants of the 
females ; and the history of Mrs. Paine's family seems to confirm it. My object 
in writing this is, that those into whose hands it may fall, who are predisposed 
to this disease, may keep a watch upon themselves ; and I exhort them to mod- 
eration in labor and physical exertion, and in all things, and that they may have 
a history, though imperfect, of the cases which have appeared in our family ; 
that they may immediately, on suspicion that they are attacked by any unusual 
thing, apply for the best help within their power. I waited some two months be- 
fore taking any measures for relief. This disease is also known as ' wasting palsy.' 
It is known in other families. The so-called living skeletons, who are exhibited 
as curiosities, are sufferers from muscular atrophy in its worst form. I am the 
oldest of five ; one sister and three brothers still enjoy fair health. None of us 
have used tobacco or spirituous liquors. 

"E. H. "Wetheebee. 

Gaed>t:b. Massachusetts, Jfareh 31, 1ST3." 

In relation to this case, Dr. Andrews, in sending me the pamphlet, 
writes, under date of March 30, 1874: 

"This man, TVetherbee, died December 23, 1873. 

"His sister has recently consulted me with symptoms of the same disease. 
The left arm and shoulder are affected. The twitching of the fibrillar is worse at 
night. I prescribed iron and quinine, and rest. I was present at your clinic at 
Bellevue two years ago when you exhibited a patient — a bridge-builder — from 
Ohio, with the disease.' 

Two members of this family, within the knowledge of the writer of 
the pamphlet, were affected with progressive muscular atrophy, and it 



PROGRESSIVE MUSCULAR ATROPHY. 507 

is probable that other members, as he was informed, before his great- 
grandfather, were its subjects. An interesting circumstance is, that two 
of the cases were females, and it is likewise a notable fact that the 
children of one of these, nine in number, exhibited no symptoms of the 
disease. We have seen that in pseudo-hypertropbic spinal paralysis 
the affection is only transmitted through the females, while progressive 
muscular atrophy, so far as this history goes, appears to be only im- 
mediately hereditary through the males. Atavism was therefore mani- 
fested in a different way than it is in the former affection. Duchenne, 
however, as we have seen, has witnessed two cases occurring in children 
in which the disease was transmitted directly through the mothers who 
were themselves the subjects of the malady. 

But nothing on this point can surpass the instructive histories re- 
lated by Dr. Naunyn 1 relative to cases brought before his medical clin- 
ic in Konigsberg. Six generations were subject to the disease. Mem- 
bers of three generations were alive at the time Naunyn delivered his 
lecture, and the clinical histories of seven cases were personally known 
to him. The oldest of these, Dorothea Braun (like Bessel), was seventy 
years old. Her father and grandfather had the affection, to her knowl- 
edge, and her father told her that her great-grandfather was also its sub- 
ject. Dorothea had eleven brothers and sisters, of whom only one, 
Minna, a sister, had the disease. Of her own seven children four wers 
affected. Of Minna's three, one dying in early infancy, two were dis 
eased. Of Dorothea's uncles, seven in number, two suffered from the 
malady. 

The table on page 508 shows at a glance the relationship of the 
several members of this remarkable family, and the channels through 
which the disease was transmitted directly, and by atavism. From its 
examination we see — 

1. None of the sons of Daniel Bessel were affected, but two of the 
daughters, Dorothea and Minna, were, and the malady was propagated 
by them. 

2. Of Minna's three children, all females, two had the disease. 

3. Of Dorothea's seven children, two boys and two girls were af- 
fected, while two boys and one girl escaped. 

4. One of the boys, Hermann, and one of the girls, Emilie, who es- 
caped, had each a boy who had the disease, thus affording two examples 
of atavism, one through the male and one through the female. 

This history is in marked contrast to that of Wetherbee so far as 
the line of descent is concerned, and the two together may be con- 
sidered as definitely settling affirmatively the question of the heredi- 
tary transmission of progressive muscular atrophy. 

: '" Ueber Hereditat der progressiven Muskelatrophie,'' reported by Dr. Eiehorst \u 
Berliner Tdinteche Wochenschrift, Nos. 42 and 43, 1873. 



508 



DISEASES OF THE SPINAL CORD. 






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PROGRESSIVE MUSCULAR ATROPHY. 509 

From some facts which will be adduced under the head of treatment 
there is reason to believe that syphilis is occasionally a cause of pro- 
gressive muscular atrophy. 

The exciting cause is often impossible of detection. This was the 
case in twenty-nine of the instances that have come under my observa- 
tion. Of the remaining twenty-three, injuries of the spine were the 
cause in two, exposure to cold and dampness in thirteen, and excessive 
muscular exertion in eight. Of these latter cases, two occurred in the 
persons of ballet-dancers, the disease making its appearance first in both 
gastrocnemii muscles simultaneously ; one in a gentleman who had 
overtasked the muscles of the upper extremities by severe and long- 
continued exertion in rowing — the muscles about the shoulders being 
affected; in two, the muscles of the right hand were first attacked, as 
the result of excessive use of the pen in writing; in one, it was induced 
by the occupation, that of a bricklayer, requiring the patient to bear 
the weight of his body, during his work, mainly on one leg — the one 
attacked; in one, it was apparently induced by running a long distance; 
in one, it began in the thenar eminence of the right hand of a bridge- 
builder; in one, it attacked the muscles of the hand and forearm, begin- 
ning in the ball of the thumb in a man whose occupation — faro-dealer — 
required him to use his thumb and fore-finger in a peculiar way for 
many hours at a time. Venereal excesses have been alleged as a cause, 
but I have seen nothing to support the assertion. 

Diagnosis. — Progressive muscular atrophy may be confounded with 
infantile spinal paralysis, spinal paralysis of adults, pseudo-hypertro- 
phic paralysis, amyotrophic lateral spinal sclerosis, and various second- 
ary forms of atrophy. 

From all these diseases it is discriminated without difficulty, if atten- 
tion be paid to its peculiar features, which in the main are as follows : 

1. The absence of fever and of pain in the back. 

2. The gradual progress of the atrophy, the muscles being attacked 
one by one and not en masse, as in the other diseases named. 

3. The fact that there is not paralysis in the proper sense of the 
word, the loss of power being simply the result of a diminished mass 
of muscle. 

4. The retention of the electric contractility so long as there are 
muscular fibres to contract and the absence of polar degenerative 
reactions. 

5. The presence of fibrillary contractions, which are very rarely 
met with in other atrophic diseases, except amyotrophic lateral scle- 
rosis, the diagnosis from which will be herewith pointed out. 

Progressive muscular atrophy, when manifested in the tongue, has 
often been mistaken for glosso-labio-laryngeal paralysis. It is readily 
distinguished, however, from this latter disease by the fact that atrophy 
is not an accompaniment of the morbid process which characterizes 



510 DISEASES OF THE SPINAL CORD. 

glosso-labio laryngeal paralysis. In progressive muscular atrophy at- 
tacking the tongue the organ is marked by knots and depressions, the 
latter corresponding to the situation of the atrophied muscular bundles 
and the former to the as yet untouched portions. In glosso-labio laryn- 
geal paralysis the tongue lies motionless in the mouth, undiminished in 
size. 

In locomotor ataxia there is sometimes a wasting of the muscles, 
but the fact that the atrophy is shown in masses of muscles at once, and 
the clinical history of the patient, will suffice to render the diagnosis 
exact. 

In rheumatic affections there is often atrophy, but this is consecu- 
tive on paralysis, and in the cases of tumors of the cord we have the 
phenomena of slow compression in addition to those of muscular atro- 

P h 7- 

In cases of injury of the cord or of the nerves supplying a part, pa- 
ralysis is the first symptom to make its appearance, though atrophy may 
very quickly follow. In such instances the electric contractility is soon 
lost. Attention to the clinical history of such cases will render a mis- 
take in their diagnosis almost out of the question. 

Prognosis. — From what has been said, it will readily be apprehended 
that progressive muscular atrophy is a very serious disease; indeed, it 
is one of the most progressive of all the affections to which the term has 
been applied. 

In only three cases have I succeeded in arresting the course of the 
disease, and in restoring the atrophied muscles. One of these was that 
of a highly-intelligent gentleman, formerly an officer in the navy, but 
now a resident of this city, whose case has already been referred to as 
having been induced by rowing; the other was that of the patient, also 
previously mentioned, in whom the affection was induced by cold, and 
which began in the right deltoid muscle. Both of these patients were 
entirely cured, regaining full muscular power. The other was a man 
who came to my clinic at the University Medical College during the win- 
ter of 1874-'75. 

In four other cases, which I saw before the disease had advanced to 
a great extent, its progress was arrested, but there has as yet been no 
restoration of the wasted muscles; in two of these there was no prob- 
able cause of the affection. 

The coexistence of a clinical history of syphilis probably makes the 
prognosis more favorable than would otherwise be the case. 

The existence of an hereditary tendency renders the prognosis much 
more grave; and the fact of the disease having lasted a longtime is also 
of unfavorable import. 

Morbid Anatomy and Pathology. — Investigations in regard to the 
morbid anatomy of progressive muscular atrophy relate to the condi- 
tion of the spinal cord, the nerves, and the affected muscles. 



PROGRESSIVE MUSCULAR ATROPHY. 51 1 

The spinal cord has been examined in cases of progressive muscular 
atrophy by Bergmann, Meryon, Gull, Luys, Lockhart Clarke, and 
others, with very different results; some of these observers finding no 
change whatever, and others detecting notable variations from the nor- 
mal structure. In three cases examined by Clarke, 1 disorganization of 
the spinal cord, especially of the gray matter, was found, with, in one 
case, deposit of amyloid corpuscles. 

More recently Hayem, a and Charcot and Joffroy, 3 have studied the 
morbid anatomy of progressive muscular atrophy with great care. In 
Hayem's case, the disease affected the muscles of the upper extremi- 
ties to such an extent as to render them powerless from the shoulders 
down. The patient died from paralysis of the diaphragm, and of pneu- 
monia. 

On post-mortem examination, the spinal cord appeared healthy to 
the naked eye. The anterior roots of the cervical nerves were, how- 
ever, notably atrophied. The most attenuated were those of the second, 
third, fourth, and fifth pairs. The sympathetic was healthy. On mi- 
croscopic examination of the cord, the most marked characteristic was 
atrophy and disappearance of the nerve-cells. In some portions there 
were none to be seen, but there were large numbers of free nuclei, 
and of cells containing many nuclei. The atrophy of the nerve-cells, 
and of the anterior cornua of gray substance, was greatest at the level 
of the second and third cervical nerves, and extended as low as the fifth 
cervical. This region was that from which the nerves supplying the 
atrophied muscles were derived. In the dorsal and lumbar regions there 
was no atrophy of nerve-cells or of nerve-roots. 

A consideration of this case shows, as Hayem remarks, that it is one 
which, during life, exhibited the usual symptoms of progressive muscu- 
lar atrophy, and that, at the post-mortem examination, lesions were 
found in the muscles in the anterior roots of the nerve, and, above all, 
in the spinal cord. The alterations from the healthy structure of the 
cord consisted of — 

1. Abnormal vascularization with dilatation, and sclerosis of the ar- 
terioles, and of the larger capillaries. 

2. A more or less abundant exudation surrounding the blood-ves- 
sels. 

3. Multiplication of the elements of the interstitial tissue (the neu- 
roglia), and finally atrophy, and disappearance of a very great num- 
ber of the nerve-cells. 

1 Beale's "Archives of Medicine," vol. iii., 1861 ; also, same, vol. iv.; also, British and 
Foreign Medico- Chirurgica* Review, vol. xxx., 1862. 

2 " Xote sur un cas d'atrophie musculaire progressive, avec lesions de la moelle," Ar- 
chives de Physiologie, No. 2, 1869, p. 221, and No. 3, 1861, p. 391. 

3 " Deux cas d'atrophie musculaire progressive, avec lesions de la substance grise et du 
faisceaux antero-lateraux de la moelle epiniere," Archives de Physiologie, Nos. 3 and 5, 
1869. 



512 DISEASES OF THE SPINAL CORD. 

These facts point to the existence of chronic inflammation of the 
gray substance of the cord, beginning in the nerve or parenchymatous 
tissue, and subsequently involving the neuroglia or interstitial sub- 
stance. 

The two cases of MM. Charcot and Joffroy have also been very care- 
fully and thoroughly studied. 

The chief features of the first case were, progressive muscular atro ■ 
phy, especially marked in the superior extremities; atrophy of the 
muscles of the tongue and of the orbicularis oris, and paralysis with 
rigidity of the inferior extremities. The patient was a woman, and, be- 
coming suddenly very weak, died asphyxiated. 

At the autopsy, the anterior roots, especially those of the cervical 
region, were found greatly atrophied and discolored. The cord ap- 
peared healthy to the naked eye, except that at the dorso-lumbar en- 
largement it was softened. On microscopical examination, however, 
the nerve-tubes of the anterior columns were discovered to be atrophied, 
a great number being only represented by the axis cylinder, while the 
connective tissue was very much increased. The posterior columns 
were not involved in the least. 

In examining the gray substance of the cervical region, the authors 
were struck with the extreme degree of atrophy which the cells of the 
anterior cornua had undergone; a large proportion of them had entirely 
disappeared, leaving no trace behind them. The posterior cornua ap- 
peared to exhibit all the qualities of the normal condition. 

The alterations in the other regions of the cord were not directly 
connected with the muscular atrophy, except as regards the medulla ob- 
longata, where the cells of the nuclei of origin of the hypoglossal were 
found to be atrophied, and even completely destroyed. In the second 
case, similar structural changes were found. 1 

As Charcot states, when the alterations of the neuroglia are very 
pronounced, the anterior horn, which is the seat of the morbid process, 
may be considerably reduced in size. This condition is well shown in 
the accompanying woodcut (Fig. 55), which represents a section of the 
spinal cord taken from the cervical region of a patient who had been 
the subject of progressive muscular atrophy — a, the left anterior horn 
of gray matter; b, the right anterior horn, the cells of which are atro- 
phied with the exception of a small group at c. The whole right ante- 
rior horn is seen to be diminished in size. 

1 These cases, which at the time were considered to be instances of progressive mus- 
cular atrophy with complications, are now to be classed under the head of amyotrophic 
lateral spinal sclerosis. I have described here the morbid anatomy exhibited by them in 
bo far as it relates to the lesion of the cells in the anterior horns of gray matter, reserv- 
ing the consideration of the other lesions for a subsequent division of the subject It 
may be said now, in anticipation of a fuller discussion, that the alterations of the gray 
matter of the anterior horns appear to be the same in the two diseases. 



PROGRESSIVE MUSCULAR ATROPHY. 513 

MM. Prevost and David 1 have recently reported a case of atrophy 
of the thenar eminence, similar to that related on page 482 as occur- 
ring in my own experience. They had the opportunity, however, of 
making a post-mortem examination, the patient dying of a wound of 
the head. The man, the subject of the disease, had had from his in- 
fancy complete atrophy of the muscles of the ball of the right thumb. 
Even the bone was atrophied. There had never been pain. 

Fig. 55. 




On post-mortem examination there were found: manifest atrophy 
of the anterior root of the right eighth cervical nerve; slight atrophy 
of the anterior root of the right seventh cervical nerve, and atrophy 
of the right anterior horn of gray matter in relation with these roots. 
The muscles of the thenar eminence were entirely destroyed ; but all 
the other muscles of the hand and arm were normal. 

In this case the relation between the spinal lesions and the affected 
muscles was sufficiently explicit. 

Still more lately MM. Pierret and Troisier 2 have examined the spinal 
cords of two patients who died of progressive muscular atrophy, and 
have confirmed in all essential respects the results obtained by the 
observers previously mentioned. The character of the lesions of the 
cord and nerves may therefore be considered as definitely ascertained; 
and it is equally an established fact, first noticed by Cruveilhier, that 

1 " Note sur un cas d'atrophie des muscles de l'eminence thenar droite avec lesions 
de la moelle epiniere," Archives de Physiologie, 1874, p. 593. 

2 " Note sur deux cas d'atrophie musculaire progressive," Archives de Physiologie, 
1875, p. 237. 

34 



514 DISEASES OF THE SPINAL CORD. 

the anterior roots of the spinal nerves derived from the affected por- 
tion of the cord and supplying the diseased muscles are generally 
found atrophied from the disappearance of a certain number of 
nerve-tubes. This is a secondary lesion resulting from the spinal de- 
generation. 

The atrophy of the muscles is due to the degeneration and ulti- 
mate disappearance of the fibrillae. To the naked eye they appear 
pale and attenuated. By microscopical examination, it is seen that 
the transverse striae of the fibrillae are in course of disappearance, 
and as the disease advances they are perceived to fade away alto- 
gether. Eventually, the longitudinal striae also disappear. At the 
same time, the muscular fibrillae break up into granules, and then 
undergo regressive metamorphosis into fat. It is not uncommon to 
see a bundle of fibrillae, in one part of which the transverse striae 
only have vanished ; in another, the longitudinal ; in another, the 
process of disintegration complete ; and in another, oil-globules occu- 
pying their place. Fat-corpuscles are frequently found deposited 
between the bundles of fibrillae. After a time the fat disappears, and 
nothing is left of the muscle but a cord of connective tissue made up 
of the perimysium. 

Sometimes the interstitial fat is deposited in such large amount as 
to take away from the atrophied parts all appearance of emaciation, 
and, in fact, to mask the essential feature of the disease. Duchenne 
has particularly called attention to this circumstance, and has given 
engravings representing patients thus affected. 

The essential points in the morbid anatomy of progressive muscu- 
lar atrophy are no longer matters of doubt. The bearing of these 
points on the real nature of the disease is next to be investigated. 

At the outset of the inquiry relative to the pathology of pro- 
gressive muscular atrophy, the question arises, Is it an affection 
of the muscles, the nerves, the sympathetic system., or the spinal 
cord ? 

As regards its being a disease primarily of the affected muscles, 
Friedreich 1 is the most strenuous contestant in support of the affirma- 
tion. His main argument is that lesions are found in the muscles 
while they are not found in the spinal cord or nervous system, except 
in a few instances. But he neglects to state these very important 
facts, that in every case he cites, in which lesions of the cord were 
not found, the examination was made before Lockhart Clarke had 
taught us how histological investigations of the nervous centres were 
to be carried on, and that in every case of progressive muscular atro- 
phy, in which the spinal cord has been examined since that time, and 
according to that method, disease of the anterior tract of gray mat- 
ter has been found. Thus the first examination which he cites was 
1 " Uebcr Muskelatrophic," u. s. w., Berlin, 1873. 



PROGRESSIVE MUSCULAR ATROPHY. 515 

made in 1858 ; the last in 1867. In the intervening period the 
lesions of the cells in the anterior horns did not attract attention — 
were not, in fact, discovered. Lockhart Clarke, Charcot, Joffroy, 
Duchenne, Hayem, Pierret, Prevost, and others, had not made the 
examinations which have placed the existence of the central lesion 
beyond a doubt. 

Now, as to the relation of cause and effect which the spinal and 
muscular lesion bear to one another, opinions vary, and the ques- 
tion appears to be one which, in its very nature, is incapable of 
being positively solved. We can only take the evidence on both 
sides, and determine the matter according to what strikes us as 
being the weight of testimony ; and this appears to be in favor 
of the doctrine of primary spinal disease. We have in support of 
this view — 

1. The fact that those cells of the cord are diseased which are in 
anatomical and physiological relation with the affected muscles. 

2. The absolute certainty that similar lesions of the anterior horns 
of gray matter will cause atrophy of muscles — infantile spinal paraly- 
sis, spinal paralysis of adults, acute myelitis, etc. In these diseases 
we know from the central as well as from the peripheral phenomena 
that the morbid process starts from the spinal cord. We have hence 
evidence that atrophy of nerve-cells will give rise to atrophy of 
muscles. 

3. On the contrary, we have nothing to show that atrophy of 
a muscle will cause inflammation and degeneration of spinal nerve- 
cells. 

4. If the disease were a primary affection of the muscular system, 
we ought to find the nerves diseased at their extreme peripheral ter- 
minations in the muscles ; such, however, is not the case. The 
ascending neuritis, which Friedreich assumes to exist, is not shown to 
be a pathological entity. Neither the patho-anatomical facts nor the 
symptoms of progressive muscular atrophy give any color of truth to 
his theory. 

It is not to be doubted, however, that peripheral lesions of the 
nervous system will cause central disease. But we can readily con- 
cede that much, without going to extreme lengths with Friedreich. 

As to the affection being a primary disease of the nerves, the only 
evidence we have of that doctrine is the fact of the atrophy of the 
anterior roots of the spinal nerves in direct relation with the atrophied 
muscles. Cruveilhier regarded this condition as the essential lesion, 
mainly, however, because he was unable with his imperfect means of 
research to discover the morbid process in the cord. This nerve-atro- 
phy is like that of the muscles — to be regarded as entirely secondary 
to the central disease, and as being directly dependent thereon. If it 
were primary or due to the muscular atrophy, we would find it not only 



516 DISEASES OF THE SPINAL CORD. 

manifested in the anterior nerve-roots but in the peripheral extremi- 
ties ; beginning in them and passing along the trunks of the nerves to 
the cord. 

When we come to consider the relation of progressive muscular at- 
rophy to the sympathetic nervous system we find little or nothing to 
warrant us in considering it as one of cause and effect. It is true that 
Jaccoud 1 and others have observed lesions of the sympathetic, asso- 
ciated with the disease in question; but Charcot, Vulpian, and Hayem, 
by the employment of the most approved methods of research, have 
failed to confirm these results; and quite recently M. Lebimoff 2 has 
most thoroughly and conclusively, in a case of undoubted progressive 
muscular atrophy, investigated the sympathetic nervous system, and 
has found neither fatty degeneration of the nervous element nor de- 
generation or proliferation of the neuroglia. All that he discovered 
was a deposit of pigmented granulations in the protoplasm of the con- 
nective-tissue cells — a condition which he very properly ascribes to the 
general exhaustion and the cachectic state of the patient. In this case 
the characteristic alterations of the cells of the anterior horns were 
very pronounced. 

Hence we are, I think, forced to conclude that progressive muscular 
atrophy is not primarily a disease of the muscles, the nerves, or the 
sympathetic system, but of the anterior tract of gray matter of the 
spinal cord. 

As to the nature of the process by which the cells are destroyed 
there is every reason to believe that it is a very slow, chronic inflam- 
mation. 

Relative to the physiological functions of the cells which are the 
seat of the disease, there is not much to say in addition to the remarks 
already made when infantile spinal paralysis and spinal paralysis of 
adults were under consideration. 

Progressive muscular atrophy, pure and Uncomplicated, is unaccom- 
panied by paralysis, except such loss of power as is directly due to the 
diminution of the volume of the affected muscles. The inference is, 
therefore, that it is not the motor cells which have disappeared or be- 
come atrophied, and yet, on post-mortem examination, we find that 
nerve-cells of some kind have been diseased. The presumption is, and 
it is reasonable, that these are cells which are specially connected with 
the nutrition of muscles — trophic cells — and that progressive muscular 
atrophy is a symptom indicating the existence of disease of the trophic 
cells. The very existence of these cells is a matter of inference, but in 
my opinion the argument in favor of the affirmative is very much 

1 " Bulletin de la societe medicale des hopitaux," 1864 ; and " Traite de pathologie 
interne," tome i., 1870, p. 357. 

2 " Recherches sur l'etat du systeme nerveux sympathique dans un cas d'atrophie mus- 
culaire progressive spinale protopathique," etc., Archives de Physiologic, 1874, p. 889. 



PROGRESSIVE MUSCULAR ATROPHY. 517 

strengthened by the facts furnished by the morbid anatomy of progres- 
sive muscular atrophy. Dr. Handfield Jones 1 has recently written for- 
cibly against the existence of any special trophic nerves, and, by exten- 
sion of reasoning, trophic nerve-cells. But he was unaware of the 
more recent researches of Duchenne and Joffroy, 2 upon which, in ac- 
cordance with these observers, I have based my views of the pathology 
of progressive muscular atrophy, and to which I have already alluded. 
We have only to take into consideration the phenomena which are ex- 
hibited in glosso-labio-laryngeal paralysis as it affects the tongue and 
progressive muscular atrophy attacking the same organ, to perceive 
how wide is the difference between the two affections. In the case of 
a lady from Rhode Island, now under my care, the thenar eminences of 
both hands, certain muscles of the arms, and others of the lower ex- 
tremities, are in a state of profound atrophy. One side of the face is 
also affected. She swallows with difficulty and speaks with great indis- 
tinctness. Here are some of the symptoms of glosso-labio-laryngeal 
paralysis to a superficial observer, but when the patient opens her mouth 
the tongue is seen not as a mass of reddened, flabby, inert muscles ly- 
ing torpid, but atrophied to a marked degree on the left side and capable 
of being moved as well as the diminished volume of muscular tissue will 
permit. Here we have atrophy of the muscular system beginning in 
the upper extremities and finally attacking — still preserving its charac- 
teristics — the muscles of the face and tongue. 

On the other hand, we may have the morbid process, which gives 
rise to glosso-labio-laryngeal paralysis, extend down the cord and 
attack the cells of the anterior horns. But it is then a paralysis which 
results, not an atrophy, and the lesions of the anterior horns are to be 
classed with the secondary degenerations of the cord. 

Are we not, from these two categories of cases, still further war- 
ranted in assuming the existence of motor and trophic cells both in the 
spinal cord proper and the medulla oblongata ? To answer this ques- 
tion in the negative it appears to me we are forced to disregard some 
of the most cogent teachings of morbid anatomy and pathology. 

Treatment. — The most approved means of treatment consist in the 
use of the primary or galvanic current to the spine, and the faradaic 
to the atrophied muscles. The former is best applied by placing one 
pole on the nape of the neck and stroking the skin on each side of 
the vertebral column with the other. The current should be as strong 
as the patient can endure. A stance should be given every alternate 
day, and should last about ten minutes. 

The faradaic current should be carefully and thoroughly applied to 

1 "Are there Special Trophic Nerves?" St. George's Hospital Reports, vol. iii., 1868, 
p. 89. 

2 " De l'atrophie aigue et chronique des cellules nerveuses," etc., Archives de Physi- 
ologie, No. 4, 1870, p. 499. 



518 DISEASES OF THE SPINAL CORD. 

every atrophied muscle within reach which responds, and should be 
powerful and slowly interrupted. In those muscles which do not con- 
tract to the induced current the primary may be employed, but such a 
course will rarely be necessary, the muscle being, in the vast majority 
of cases, beyond the reach of remedial means. It is probably entirely 
atrophied. 

By the use of these measures I have succeeded in curing three 
cases. These have already been referred to. The last, a man whose 
thenar and hypothenar eminences were markedly atrophied, and in 
whom the flexores carpi ulnaris and radialis were already affected, came 
with his physician to my clinic at the University Medical College. I 
advised the treatment mentioned ; it was carried out, and in the course 
of two months the muscles were almost completely restored. The 
atrophy showed no further disposition to extend. I have since heard 
that this patient entirely recovered. 

If there is the least suspicion of syphilis, iodide of potassium in 
large doses should be administered. In the case of a gentleman affected 
with progressive muscular atrophy, with an undoubted clinical history 
of syphilis, and who, residing out of New York, I see only about once a 
month, a very positive arrest of the disease appears to have resulted 
from this treatment. When he first consulted me the right thenar and 
hypothenar eminences were entirely destroyed ; the interossei and 
lumbricales were nearly so. All the muscles of the forearm were 
more or less affected, and the disease was manifesting itself in the left 
thenar eminence, which was already decidedly wasted. He was at first- 
treated by electricity, but there was no improvement, and while this 
agent was being used the left triceps showed signs of atrophy, and 
fibrillary contractions occurred in the muscles of both arms, which were 
not yet wasted, and in those of the trunk. The electricity was now 
discontinued after having been employed over six weeks, and the iodide 
of potassium was administered in gradually-increasing doses, beginning 
with ten grains three times a day. At about the time thirty-grain 
doses were reached, the fibrillary contractions ceased. He continued 
to increase the doses till he took half an ounce a day. There were 
then no contractions, and no further extension of the atrophy had taken 
place. The medicine was now discontinued for ten days, when it was 
resumed and continued as before. He still takes the iodide in gradu- 
ally-increasing doses every alternate month, up to forty grains three 
times a day. A year and more has now elapsed since I first saw this 
patient, and there has been no advance of the disease since the treat- 
ment with the iodide was begun, and no fibrillary contractions in any 
part of the body since their disappearance nearly a year since. 

A few cases of improvement have been reported as occurring from 
hydro-therapeutics. 

It is very probable that the majority of the instances in which amel- 



PROGRESSIVE FACIAL ATROPHY. 519 

iorations or cures are asserted to have been produced by one thing and 
another were not in reality cases of progressive muscular atrophy. 
Every physician, whose practice is extensive in the class of nervous 
diseases, has doubtless had many patients consult him in whom the 
diagnosis of progressive muscular atrophy has been made, but who 
were affected with very different affections from that very intractable 
malady. 

b. Progressive Facial Atrophy. 

The remarkable affection now to be described under the name of 
progressive facial atrophy has been known since 1825, when Parry ' de- 
scribed the case to w T hich all subsequently noticed have a more or less 
close resemblance. Although cases were subsequently reported it 
seems to have attracted little attention till Lande, 2 in 1869, and Fremy, 3 
in 1872, published their monographs. No account of the disease has 
yet appeared in this country, and only one case has been reported in 
Great Britain since Parry's above cited. This case, described by Dr. 
Moore, 4 of Dublin, appears to have been a typical one, which is certainly 
not the fact with several of those quoted by Fremy. 

The disease, which was called by Romberg — who was the first to 
give it an independent existence — trophoneurosis facialis, by Moore uni- 
lateral atrophy of the face, and by Lande laminar aplasia, does not 
seem to be very common. Eleven cases have been collected by Lande, 
and Fremy adduces twenty-four additional ones, several of which, how- 
ever, are, as I have said, not cases of the disease in question. Three 
instances only have come under my observation. 

Various theories relative to its essential character have been ad- 
vanced. These, with the reasons which have induced me to consider 
it as having affinities with progressive muscular atrophy, will be fully 
brought forward under the head of morbid anatomy and pathology. 

Symptoms. — The first case which occurred in my own experience 
was that of a lady forty-one years of age, who consulted me in January, 
1874. Twenty years previously she had noticed as the first symptom 
a very slight degree of weakness in those muscles of the left side of 
the face concerned in the movements of the lips, so that, when she 
attempted to smile or laugh, the mouth did not expand to the same 
extent on that side as on the right. 

This condition lasted several months without giving her much an- 
noyance, till on waking one morning she noticed a pale, almost white 
spot on the skin immediately over the left malar bone. This was of a 

1 Cited by Romberg, " Lehrbuch der Nervenkrankbeiten des Menscben," Berlin, 1854. 

2 "Essai sur l'aplasie lamineuse progressive," Paris, 1868. 

3 "Etude critique de la trophonevrose faciale," Paris, 1872. 

4 u Case of Unilateral Atropby of the Face," Dublin Quarterly Journal of Medical 
Science, 1852, p. 245. 



520 DISEASES OF THE SPINAL CORD. 

sub-rotund form, and gradually enlarged to the size of a dollar, becom- 
ing paler in hue and more irregular in outline. 

Then she began to notice that there was a lack of the fullness which 
characterized the right side of the face, and this was especially evident 
at the situation of the spot. Here a depression was plainly to be seen. 

Then a second depression, but this time without being preceded by 
paleness of the skin, began to appear. This was situated at about the 
middle of the chin, half an inch to the left of the median line. This 
extended most toward the right side, and in the course of two years had 
reached the median line and had a length of about two inches toward 
the angle of the mouth. 

During the time that these depressions were extending she had been 
subject to fibrillary contractions all over the left side of the face. 

There were no other symptoms, beyond the exceedingly gradual ex- 
tension of the first depression, for fifteen years. Then a third spot, sit- 
uated on the skin immediately over the angle of the jaw, on the left 
side, appeared and gradually extended as had the first. A depression 
likewise occurred in the soft parts at this spot, and, extending, finally 
reached the first depression. 

When she consulted me there was a marked difference in the size 
of the two sides of the face, especially the lower part. The skin over the 
forehead on the left side was glossy and the belly of the occipito-fron- 
talis muscle was decidedly thinner than that of the opposite side. The 
left eye appeared to be less prominent than the right, the temporal 
muscle was thinner, and the masseter was certainly not so thick as its 
fellow. All the muscles of the angle of the mouth, as well as the left 
half of the orbicularis oris, were atrophied. The depression on the chin 
involved the depressors of the lower lip and angle of the mouth. The 
elevator of the upper lip and of the ala nasi was not affected. 

The skin over the left side of the face was apparently attached firm- 
ly to the parts below, and did not admit of being moved or pinched be- 
tween the fingers. It was decidedly thinner than that of the other 
side. 

I could not ascertain that there was any atrophy of the bones. The 
pulsations of the carotid, temporal and facial arteries were as strong on 
the left side as on the right. 

There was no discoloration or falling off of the hair, no aberration 
of sensibility, no unilateral sweating, and no difference in the amount 
of sebaceous secretions on the two sides. 

The motor power of the left side of the face was weaker than 
that of the right. When the mouth was expanded, the action was 
markedly less on the left than on the right side. The left buccinator 
was thinner and weaker than the right, the left half of the orbicularis 
oris did not contract to the same extent as the right when the mouth 
was pursed up, and the jaws were less strongly brought together on 



PROGRESSIVE FACIAL ATROPHY. 521 

the left than on the right side. Yet there was no paralysis in any 
muscle, and each, on very thorough exploration with the faradaic cur- 
rent of moderate power, contracted well. 

Examined with the sesthesiometer the sensibility was found to be 
intact. At no time had there been numbness, pain, or any abnormal 
sensation. 

The tears, saliva, and buccal and nasal mucus, did not appear to be 
altered, either in quality or quantity. 

The tongue was not involved, and, when protruded, came out 
straight. Deglutition was unimpaired. 

The temperature of the two sides of the face was examined by a 
delicate thermometer, but no difference could be found to exist; but in 
October, 1875, I again had the opportunity of examining this patient, 
and then, by means of Dr. Lombard's thermo-electric apparatus, I as- 
certained that the left was .7° centigrade lower in temperature than the 
right side. The general health was excellent. 

Although not allowed to have a photograph taken, I obtained the 
permission of this lady to examine the muscular tissue, and punct- 
uring the buccinator with Duchenne's trocar I succeeded, with some 
little difficulty, in extracting a fragment for microscopical investiga- 
tion. For purposes of comparison, I operated in the same manner on 
the corresponding part of the opposite muscle. The results of the ex- 
amination will be given when we come to the consideration of the mor- 
bid anatomy and pathology. 

A second case came under my observation shortly after the publica- 
tion of the foregoing in the sixth edition of this work, but the patient, 
a woman of about forty years of age, passed from my notice before I 
had the opportunity of making a study of the phenomena, or even of 
making notes of them. My recollection, however, is clear that the 
muscles supplied by the facial, the motor branch of the fifth, and the 
hypoglossal, were the seat of atrophy. 

A third case * forms the subject of a communication read before the 
New York Neurological Society, March 2, 1880. The patient was a 
girl fourteen years old. The affection was of gradual growth, and 
did not attract marked attention till about two years previously to 
my seeing her. It was then noticed that the left side of the face was 
different from the right, and careful examination showed that there 
were two depressions : one just above the angle of the mouth, and one 
just below and a little external to the other. Subsequently, the one 
above and slightly in front of the left ear began to appear. All of 
them have continued to increase up to the present time (January 24, 
1881), and in addition there is a decided difference in the size of the 
two sides of the face (Fig. 56). There has at no time been any appar- 

1 "A Case of Progressive Facial Atrophy, with Remarks on the Pathology of the 
Disease," Journal of Nervous and Mental Diseases, April, 1880. 



522 DISEASES OF THE SPINAL CORD. 

ent paralysis. Occasionally there are what may be called paroxysms 
of numbness, extending over the left side of the face and never pass- 
ing the mesial line. These only last a few minutes. At no one of 
my examinations have I been able to detect any loss of sensibility 

Fig. 56. 



except of a limited region over the left half of the orbicularis oris 
muscle. The centres of atrophy were not preceded by any whiteness 
of the skin. The hair, however, is markedly thinner on the antero- 
superior auricular centre of atrophy than on the sound side. 

Examination shows, what had not previously been noticed, that 
the left half of the tongue is much smaller than the right, and that 
the palatine arch on the same side is flatter than on the opposite side. 
The tongue when protruded is deflected toward the affected side. 
There is no difficulty of swallowing, no defective .articulation, no loss 
of taste, and no deficient sensibility of the tongue or any part of the 
mucous membrane lining the buccal cavity. 

The first symptom which ordinarily makes its appearance is the 
white spot, which shows an evident tendency to extend. The centre 
of greatest atrophy is in intimate topographical relation with this 
spot, and it is here, therefore, that the depression is most marked. 

The skin becomes thinner, as is well perceived when a fold of it is 
pinched between the fingers, as can be done in the early stage of the 
disease. The cellular tissue also diminishes in volume. 

The hair, eyebrows, eyelashes, and beard, generally either fall out 
cr lose their color, changing to a gray or even perfectly white hue. 



PROGRESSIVE FACIAL ATROPHY. 523 

The sebaceous secretion is usually less on the affected than on the sound 
side. Sometimes the larger arteries are apparently diminished in cali- 
bre, but the capillary circulation, as evidenced in blushing, is as active 
on the affected side as on the other. 

The muscles have generally been atrophied both in thickness and 
length. Fibrillary contractions have sometimes been observed. It is 
probable they would be generally noticed if attention were directed to 
them. 

It is rarely the case that sensibility is disturbed ; but occasionally 
neuralgic pains have been experienced. The cartilages and even the 
bones have been sometimes the seat of atrophy. 

The special senses remain intact, and the secretions of the tears, the 
saliva, and the buccal mucus, are not diminished. 

Of the eleven cases collected by Lande, the tongue was atrophied on 
the side corresponding to the facial disease in five cases, and, when 
protruded, pointed toward the affected side. 

In several cases the atrophy extended to the veil of the palate and 
the uvula; but the function of deglutition has never been impaired. 

In three of the cases cited by Lande, the atrophy affected the 
larynx. Phonation was impaired in one of these instances. 

In none of Lande's cases in which the point was inquired into was 
there any difference in the temperature of the two sides. In five of 
Fr£my's cases the affected side was of a temperature lower from a few 
tenths to one and a half degree. 

In no case has there been complete paralysis of any muscle, and the 
portion which remains, always contracts to the excitation of the elec- 
trical stimulus. 

Fremy's statistics are very much to the same effect as those of 
Lande, though they are, I think, open to the objection that some of his 
cases were not true instances of the disease. Of twenty-seven cases 
cited by him, of which details are given, the tongue was affected eight 
times, the lips nine, and the veil of the palate five times. In seven 
other cases no statement is made in regard to these points, and in one 
it is vaguely stated that there was buccal atrophy. In four of these 
cases the affection involved at the same time both lips, the tongue, the 
veil of the palate, and its pillars on one side. 

The progress of the disease is exceedingly slow, the condition exist- 
ing in many cases for several years. It appears, however, to be dis- 
tinctly progressive in character. No death has occurred from it, nor 
has any post-mortem examination been made with the view of inquiring 
into the nature of the affection in any patient dying of an intercurrent 
disease. 

The accompanying figures from Lande represent the face of a 
woman affected with progressive facial atrophy. In Fig. 57 a 
front view of the countenance is given, and the atrophy of the left 



524 



DISEASES OF THE SPINAL CORD. 



side is clearly shown. Fig. 58 represents the left sfde of the face ; 
and, for purposes of comparison, the right, unaffected side, is given 
in Fig. 59. 



Fig. 58. 



Fig. 



Fig. 






Causes. — Little is known relative to the etiology of this singular 
disease. It appears, however, generally to originate during early or 
adult life, and females are more subject to it than males. In one case 
it ensued after a fall on the head, and in one it followed an attack of 
scarlet fever. No evidence of hereditary transmission has been ad- 
duced. 

Diagnosis. — Lande gives a long list of diseases from which facial 
atrophy is to be diagnosticated. I do not see that the affection is likely 
to be confounded with any other than progressive muscular atrophy, 
and, perhaps, in some cases, in its early stages with facial paralysis. 

As regards the first of these — progressive muscular atrophy — it 
rarely if ever begins in the face, and is not confined to that part of the 
body in any case. Moreover, there is discoloration of the skin, and no 
cutaneous atrophy. Instead of being tightly stretched over the soft 
parts below, the skin is loose and can be easily taken up in a fold be- 
tween the fingers. When the face is its seat, as it sometimes is, second- 
arily, its manifestations are not confined, as are those of facial atrophy 
heretofore observed, to one side. The lesions as regards the face, the 
tongue, and deglutition and phonation, are much more profound in pro- 
gressive muscular atrophy than in facial atrophy. 

Relative to facial paralvsis (Bell's) there can ordinarily be no diffi- 
culty in making a diagnosis. As in my case, there may be a marked 
weakness of the facial muscles in the first stage of the disease under 
notice. But the mode of origin — Bell's paralysis coming on suddenly 
— and the fact that in it the electric contractility of the muscles is al- 
ways diminished, while in facial atrophy it is unimpaired, will suffice 
for the distinction. 

Prognosis. — No case of a cure is on record. The affection is not 



PROGRESSIVE FACIAL ATROPHY. 525 

one which, as heretofore observed, terminates in death, but it is evident 
that there are cases in which it shows a tendency to involve organs of 
which the perfect integrity is essential to life. 

Morbid Anatomy and Pathology. — Bergson, 1 who appears to have 
been the first to study the disease under consideration, regarded it as 
not due to either disorder of the motor or seDsory nerves or of those 
which preside over the glandular secretions. Without indicating the 
precise primary seat of the affection, he looked upon it as essentially 
consisting in a morbid state of the layer of cellular tissue situated be- 
tween the skin and the muscles. 

Other cases were reported, and in 1851 Romberg 9 described it as a 
" tropho-neurosis of the face," a disease characterized by atrophy but 
of which the primary seat was unknown. 

Lasegue 8 reported a case in 1852 under the title of " partial atrophy 
of the face," and Moore, 4 in the same year, called it "unilateral atrophy 
of the face." 

None of these writers made any decided effort to locate the disease 
or to interpret its real nature till, in 1860, Samuel, 6 citing a well-marked 
case, first reported in 1848 by Hueter, advanced the opinion that pro- 
gressive facial atrophy was an affection of the trophic system of nerves, 
and, following Moore, he designated it unilateral atrophy of the face. 

Then, as we have seen, Lande, 6 in 1809, wrote a very complete 
monograph on the disease, which he called " laminar aplasia " (aplasie 
lamineuse), by which term he intended to convey the idea which he 
entertained of its nature, that it was an affection of the cellular tissue 
primarily. 

Subsequently, Eulenburg 7 very fully described the malady under 
the name of " hemiatrophia facialis progressiva," and, taking into con- 
sideration the fact that the manifestations of the disease are exhibited 
in those parts which are supplied by the fifth pair of nerves, he regarded 
it as the result of a lesion of this system, or at least of a derangement 
of its function. 

Finally, Fremy, 8 in a monograph of great excellence, enters at 
length into a consideration of the pathology of the disease, and con- 
cludes that it is to be classed with those trophic neurotic disorders which 

1 " De Prosopodysmorphia sive nova Atrophia facialis," Berlin, 1837, cited by Lande. 

2 " Klinische Wahrnehmungen und Beobachtungen," Berlin, 1851. 

3 "Atrophie partielle de la face," Archives Generales, tome xxix., 1852. 

4 " Case of Unilateral Atrophy of the Face," Dublin Quarterly Journal of Medical Sci- 
ence, 1852. 

5 " Die tropischen Xerven," Leipzig, 1860. 

6 "Essai sur l'aplasie lamineuse progressive (atrophie du tissue connectif ) celle de \a 
race en particulier," Paris, 1869. 

T " Lehrbuch der functionellen Nervenkrankheiten," Berlin, 1871. 
8 " Etude critique de la trcphoi.evrose faciale (Physiologie pathologique)," Paris, 
1572. 



526 DISEASES OF THE SPINAL CORD. 

have been studied by Romberg, Samuel, Charcot, and Vulpian, and 
that it essentially depends upon derangement of the trifacial nerve. 

All these opinions have been thoroughly considered by Vulpian. 1 
He shows very conclusively that progressive facial atrophy is not a 
disease of the sympathetic system, and then, in further illustration of 
his views, says : 

" Certain peculiarities of this affection seem to indicate that the tro- 
phic disorder of the face is produced by an intracranial lesion. But the 
difficulties are so great in the way of imagining that a limited lesion 
could give rise to all the alterations which occur in the face, the hair, 
the buccal cavity, and even in the neck, as in some cases, that we can 
see how M. Lande was led to reject the idea of a primitive lesion of the 
nervous system, and to admit only a protopathic lesion of the cellular 
tissue of the face. At the same time I do not think that his doctrine 
will obtain many partisans. Indeed, it is very difficult to abandon 
the idea of an intracranial lesion as the cause of the trophoneurosis. 
This affection is produced in a certain number of cases as a consequence 
of traumatic violence inflicted on the head or face. Its development is 
accompanied, in the great majority of cases for several years, with pains 
of greater or less violence seated in the head, ordinarily toward the 
fronto-temporal region. Sometimes there are spasmodic movements of 
the muscles of the face or of the jaws. In some rare cases there has 
been numbness in the superior extremity of the opposite side. These 
are the circumstances which seem to point to a cerebral lesion. But 
we cannot affirm that such lesions exist, while we have no post-mor- 
tem examination to enlighten us on this point, and while we are em- 
barrassed to designate a seat for the lesion, which can reasonably ex- 
plain all the phenomena of the disease. It has been proposed to at- 
tribute the trophoneurosis to a lesion of the ganglion of Gasser, but can 
we cite a single case in which lesions of this organ have existed in con- 
junction with an ensemble of symptoms such as that presented by the 
disease under notice ? If it be true that the greater part of the altera- 
tions produced in the malady are in the region supplied by the trigem- 
inus, and even in the course of certain of its branches (cicatricial de- 
pression of the forehead in the course of the frontal branch), we are com- 
pelled to admit that it is not so with all the changes (for example, those 
of the neck, rare, it is true). The special atrophy which is shown in 
the affected regions is not easily explained in the present state of our 
knowledge by the modifications of nutrition resulting from lesions of 
the trigeminus. We see nothing similar to the lesions of facial tropho- 
neurosis produced as a consequence of experiments made on this nerve 
or on the ganglion of Gasser. We ought not to forget, however, the 
nutritive troubles of the cornea, so common in lesions of the ganglion 
of Gasser and rare in facial trophoneurosis. Then in some cases there 
1 " Lecons sur l'appareil vaso-moteur," tome ii., 1875, p. 432. 



PROGRESSIVE FACIAL ATROPHY. 527 

is atrophy of certain facial muscles, whatever M. Lande may say to the 
contrary ; and we do not know, either clinically or by experimentation, 
that muscular atrophy is ever directly produced by alterations of the 
trigeminus or its ganglion. For to speak only of the tongue, the lat- 
eral half of which is so often atrophied in facial trophoneurosis, I have 
demonstrated that section of the lingual nerve is not followed by appre- 
ciable atrophy of the lingual muscles. 

" The difficulties which we encounter, when we attempt to connect 
the trophoneurosis with a lesion of the trigeminus, are increased, when 
we seek to explain the production of this disease by an encephalic 
lesion seated, for example, in the vicinity of the nucleus of origin of 
the fifth pair. 

" To conceive an hypothesis so little plausible, we would be forced to 
suppose the existence of multiple lesions seated in one of the halves of 
the isthmus of the encephalon. But all tentative explanation appears 
to me to be perfectly vain, since we are ignorant whether there is or is 
not a primary lesion of the nerves or the nerve-centres. We can, 
however, positively affirm that, taking into consideration all the char- 
acteristics of facial trophoneurosis, it is not due to vaso-motor pertur- 
bation acting on the parts which are the seat of the disease." 

As we have seen, there has been thus far no examination of the 
nerve-centres, the nerves, or the muscles. But, in the case which was 
under my observation, I obtained, as stated, portions of the sound and 
atrophied buccinator muscles, and submitted them to careful micro- 
scopical examination. The result was that I ascertained that the fibril- 
las of the atrophied muscle exhibited no evidence whatever of degen- 
erative changes — the transverse and longitudinal striae were distinct, 
and there were no traces of fatty degradation. But the transverse 
diameter was reduced to about one-third the normal size, as is seen in 
the cuts herewith given, which are drawn from the camera lucida to an 
exact and uniform scale when magnified four hundred diameters. In 
Fig. 60 is shown a single fibre from the right buccinator muscle, and 
in Fig. 61 three fibres from the corresponding part of the left bucci- 
nator. Fig. 62 represents a transverse section of the right, and Fig. 
63 of the left buccinator muscles. 

Examination also shows that not only is the diameter of the fibrillse 
markedly diminished, but the length is also lessened, as is evidenced 
by the fact that the transverse striae are very much closer together in 
the atrophied than in the sound fibrillae. 

It will likewise be perceived that there is in the affected muscle a 
notable diminution of the thickness of the layers of the internal perimy- 
sium, or connective tissues, which separates the fibres from each other. 
This tissue appears to be somewhat hypertrophied on the right side. 

This, therefore, constitutes the first positive contribution to the 
morbid anatomy of progressive facial atrophy, but, small as it is, it 



528 



DISEASES OF THE SPINAL CORD. 



affords very important indications in regard to the nature and seat of 
the affection. 

In the third case, the one of which the photograph has been given, 
I obtained by like means portions of the muscular fibre from each 



Fig. 60. 



Fig. 61. 




Fig. 62. 




Fig. 63. 




side, and they were exhibited to the Neurological Society. They were 
taken from the buccinators. In the one from the right or normal mus- 
cle, the primitive bundles are seen to be of full size and in every respect 
of healthy appearance. In the left or affected muscle, the bundles are 
perceived to be less than one third the diameter of the others, and to 
be much paler in hue. There is no trace of fatty degeneration, not a 
single fat-corpuscle or oil-globule being visible anywhere. The differ- 
ence is so striking, that one can scarcely resist the at least momentary 
belief that a sudden change in the magnifying power has been made. 
Accurate measurement shows that the bundles of fibres from the sound 
muscle are of the average diameter of g-^-g- of an inch, while those from 
the unsound muscle are only 2W0 °f an mcn - The size of the fibres 
from the sound side is, therefore, greater than th.at ordinarily existing 
in the facial muscles, and may probably be indicative of hypertrophy. 

Thus, in two cases in which microscopical examination has been 
made of the muscular tissue in progressive facial atrophy, there has 
been found an identity of lesions — atrophy without degeneration. I 
hence feel warranted in concluding, at least till these results are suc- 
cessfully controverted, that this is one of the concomitants of the 
disease. 

It shows that progressive facial atrophy is not one of those diseases 
manifested by degenerative changes of the muscles such as we have 
seen take place in infantile paralysis, spinal paralysis of adults, pseudo- 
hypertrophic paralysis, and progressive muscular atrophy. It is an 



PROGRESSIVE FACIAL ATROPHY. 529 

atrophy pure and simple, without the slightest tendency to degen^ 
eratiou. 

So far as analogy is concerned, there is a marked affinity, not to say 
resemblance, between the symptoms of progressive muscular atrophy 
affecting the muscles of the face, the tongue, and the pharynx, and 
those of some cases of progressive facial atrophy, in which not only the 
face is involved, but also the tongue, and in one case at least the larynx. 
We have seen that in glosso-labio-laryngeal paralysis the muscles of 
the same regions are involved, but instead of atrophy we have paralysis. 
Now, when we come to seek out the primary seat of progressive muscu- 
lar atrophy affecting the face, tongue, and throat, and that of glosso- 
labio-laryngeal paralysis, we find both in the bulb and especially in the 
nuclei of origin of the facial, the hypoglossal, the spinal accessory, and 
pneumogastric nerves. If two such different but cognate diseases may 
occupy the same anatomical situation, why may not progressive facial 
atrophy, different but cognate, be also an affection of the same region ? 
The fact that the atrophy involves other parts than the muscles, is no 
valid objection against this hypothesis. We have seen that in infantile 
spinal paralysis there is sometimes an atrophy of the bones. And yet 
we all agree to consider this disease as a primary affection of certain 
cells in the anterior tract of gray matter. 

The examination of this case, as of the two others I have witnessed, 
shows that muscles supplied by the motor branch of the fifth nerve, 
by the facial and by the hypoglossal, are atrophied ; that the skin, hair- 
bulbs, cellular tissue, and even the bone (temporal), are similarly affect- 
ed ; and that there are sensory disturbances in the skin supplied by the 
fifth nerve. Under these circumstances I arrive at the conclusion that 
the nuclei of these nerves are the primary seat of the disease in this 
case. 

The only other view that it appears necessary to discuss in this con- 
nection is the one that all the phenomena may be the result of primary 
implication of the fifth nerve or its nuclei. The involvement of the 
motor nucleus only would certainly not account for the multiple mus- 
cle lesions observed in this case ; the only muscle affected supplied by 
the motor branch of the fifth nerve is the temporal, and this only in a 
very limited portion of its substance. We have, therefore, merely to 
inquire as to the implication of the sensory nucleus, it being admitted 
that the motor nucleus is to some extent affected, as shown by the 
effect produced upon the temporal muscle. The existence of a third 
root, as contended for by Merkel, 1 and to which he assigns trophic 
functions, can scarcely be regarded as demonstrated ; and, though its 
probability may be admitted, we need not in the present state of our 
knowledge take its possible influence into consideration. So far as the 
derangements of sensibility are concerned, it is conceded that they are 
1 "Die trophischen Wurzel der Trigeminus," Centralblalt, 1874, p 902. 

35 



530 DISEASES OF THE SPINAL CORD. 

due to lesion of the sensory nucleus or of the nerve itself in some part 
of its course. 

Now, how far could a lesion of the nucleus of the sensory root of 
the fifth nerve, or one of the root itself, tend to produce all the phe- 
nomena observed in. this case and others of progressive facial atrophy ? 

If the intracranial portion of the nerve be divided, we meet, in 
addition to loss of sensibility in the parts to which the nerve is distrib- 
uted, with an invariable series of results which are entirely different 
from those observed in progressive facial atrophy. These, however, 
are intimately related to the function of nutrition. Thus, the cornea 
ulcerates, the conjunctiva becomes inflamed, the glands innervated by 
the nerve have their functional activity diminished or altogether ar- 
rested, and occasionally, apparently by reflex influence, ecchymoses 
appear in the lungs and stomach. 

Certainly these are not the accompaniments of progressive facial 
atrophy. 

The phenomena due to an irritation of the sensory nucleus, or of 
the nerve in any part of its course, are so entirely different from those 
characterizing the disease in question, that it is not necessary to dwell 
upon them more particularly. 

It appears to me, therefore, that all the atrophic phenomena present 
in cases of progressive facial atrophy are, like those met with in pro- 
gressive muscular atrophy and spinal paralysis of infants and adults, 
the result of lesion of the nuclei of motor nerves — and probably of 
trophic cells — forming with the motor cells the centres of origin of 
these nerves. In these diseases atrophy takes place without the inter- 
vention of any sensory nerve or sensory root, and there is, therefore, no 
necessity for the introduction of the sensory part of the trigeminus into 
the pathological circle presiding over progressive facial atrophy. 

So far as the motor nerves which are in relation with the parts af- 
fected in progressive facial atrophy are concerned, we know very well 
that, in other diseases in which their functions are abolished wholly or 
in part, the resulting paralysis is always accompanied with atrophy — 
the nerves, of course, containing the fibres coming both from the trophic 
and motor cells of the nuclei. Take, for instance, the hypoglossal, a 
purely motor nerve. There are a few cases on record in which the 
hypoglossal, on one or both sides, has been so compressed by tumors 
that its functions were completely interrupted, and this interruption 
was invariably followed in a short time by atrophy. Lockhart Clarke 
divided one of the hypoglossal nerves in a rabbit, and within a month 
after the operation the corresponding half of the tongue was markedly 
atrophied. 

It may be well to allude to the theory that progressive facial atro' 
phy is the result of lesion of the sympathetic system — if only to say 
that there are no facts which tend to its support. 



PROGRESSIVE FACIAL ATROPHY. 531 

In an interesting paper based upon two cases, Dr. Bannister 1 arrives 
at the conclusions that the trophic functions of the fifth nerve are es- 
pecially implicated, and that in some cases there are positive lesions of 
other cranial nerves. He considers it proved that the symptoms indi- 
cate a chronic trophic asthenia or paralysis rather than any irritative 
action. 

I am, therefore, of the opinion that progressive facial atrophy is an 
affection of the trophic cells of the bulb which are the nuclei of the fa- 
cial, the hypoglossal, and the spinal accessory nerves ; that ordinarily 
the lesion does not extend farther than the facial, but that sometimes 
when the tongue is involved it reaches the nucleus of the hypoglossal 
and occasionally that of the spinal accessory. In these cases in which 
there are aberrations of sensibility the nucleus of the sensory root of 
the fifth pair may be affected, and in those in which the temporal and 
masseter muscles are involved the motor root may also be implicated. 
Or the pain which is sometimes an accompaniment of the disease may 
be due to the contracting process going on in the muscles and con- 
nective tissue by which the terminal branches of the trigeminus are 
compressed. 

Why the atrophy should so generally affect the left side of the face 
in preference to the right, I do not pretend to explain ; but, since the 
recognition of aphasia and its association in the vast majority of cases 
with lesions of a circumscribed region of the left hemisphere, we need 
not be surprised at the additional instance of hemitopology, incom- 
plete as it is, afforded by progressive facial atrophy. 

Finally, the question may be asked, Why should the manifestations 
be restricted to one side ? I should answer that I do not know, any 
more than I am aware why ptosis or external strabismus should affect 
the eyelid and eyeball of one side ; or why hemi-chorea should exist ; or 
why, when a person has an attack of cerebral haemorrhage, he should 
not straightway have another on the opposite side of his brain. 

The first two cases reported occurred on the left side, then there 
was one on the right, and then eight on the left. If the third case had 
escaped observation, we should have had to appearance a uniform im- 
plication of the left side, to the exclusion of the right. Now about a 
dozen cases are reported as involving the right side. 

It appears to me, however, that the indisposition manifested to pass 
the mesial line is a strong argument against the affection being a local 
lesion only. 

Treatment. — Slight success was obtained by Hueter and Moore by 
the use of faradaic currents to the atrophied region, I employed both 
these and the primary current, the latter to the nucha as well, in two 
of the cases under my care, but without perceptible effect. I also ad- 

1 " Progressive Facial Hemi-atrophy," Journal of Nervous and Menial Diseases, Octo* 
ber, 1876. 



532 



DISEASES OF THE SPINAL CORD. 



ministered strychnia and other tonics without benefit. This treat- 
ment, however, seems to be indicated, and is in general urged by 
those who have written on the subject. No cure has yet been re- 
ported. It must be borne in mind that diseases which are slow to 
advance are also slow to recede. 



III. 

INFLAMMATION LIMITED TO THE POSTERIOR TRACT OF GRAY MATTER 
OF THE SPINAL CORD. 

The posterior tract of gray matter, the columns of Burdach, or the 
postero-external columns, and the columns of Goll, or postero-median 
columns, are probably the only channels by which sensations reach 
the brain from the parts below. Recently Gowers 1 has described a 
tract on the periphery of the cord, situated externally to the crossed 
pyramidal tract in lower levels of the cord, and anteriorly to it in 
higher levels, which degenerates upward. This distinguished investi- 




Diagram oi a section of the spinal cord in the cervical region. (Gowers.) 

A. C, anterior commissure. ~P.C, posterior commissure. I. g. s., intermediate gray sub- 
stance. P. Cor., posterior cornu. C. C. P., caput cornu posterioris. L. L. L., Lateral 
limiting layer. A.-L. A. T., antero-lateral ascending tract, which extends along the 
periphery of the cord. 

gator considers that the sensations of pain and temperature are trans- 
mitted to the brain through this tract, but as yet this view has not 
been confirmed by sufficient evidence to make it conclusive. The 
fibres which constitute the posterior nerve-roots do not, on their en- 

1 "Diagnosis of Diseases of the Spinal Cord," 18?9. 



INFLAMMATION OF THE POSTERIOR TRACT OF GRAY MATTER. 533 

trance into the cord, follow any uniform course. Some of them pass 
directly over to the motor cells in the anterior horn of the same side ; 
others terminate in the cells of the posterior horn either at the level 
at which they enter the cord, or else after passing upward or down- 
ward for a short distance ; some seem to approach and probably end 
in the group of cells situated near the junction of the posterior horn, 
and the posterior commissure known as the vesicular column of Clarke ; 
others pass by way of the posterior commissure to the column of Bur- 
dach on the opposite side ; and others again enter the columns of Coll 
and Burdach on the same side. 

The column of Goll, and possibly part of the column of Burdach, 
are made up of long fibres which pass up the entire length of the cord 
and decussate in the pons. This tract unquestionably is the conduct- 
ing path for the muscular sense. 

The tracts through which sensations of pain, touch, and temper- 
ature are transmitted to the brain are not definitely determined. To 
Brown-Sequard we are indebted for a knowledge of the fact that the 
sensory tract, with the exception of the muscular sense, decussates 
almost immediately after entering the cord. If, therefore, a lateral 
half of the spinal cord be divided so as to include the whole of the 
gray matter, the animal upon which the experiment is performed 
loses sensibility in the parts below, on the opposite side of the body, 
and — which is not, however, a matter of present inquiry — motion on 
the same side. 

Brown-Sequard's investigations led him to believe that sensory im- 
pressions were conducted to the brain through the posterior horns of 
gray matter ; but the probability is, though the question is not yet 
definitely settled, that sensations of pain and temperature reach the 
brain through Burdach's column, passing up on the side opposite 
to that on which the nerve-roots enter the cord. The sensation of 
touch may be transmitted through the same channel, but there is 
some evidence which points to the partial confirmation of Brown- 
Sequard's theory, and perhaps it may yet be shown that the sense 
of touch may reach the brain through the posterior columns of gray 
matter. 

Cases in which phenomena of loss of motion on one side and of 
sensibility on the other are coexistent from spinal disease are by no 
means very infrequent. Several such have been under my care in hos- 
pital and private practice, and I have always attributed them to a 
lesion of one lateral half of the cord disturbing the power of motion 
on the same side and of sensation on the other. 

But experiment shows that, while one part of the posterior nerve- 
roots passes over to the opposite side immediately on its entrance into 
the cord, another part passes upward and another downward. The 
effect, therefore, of a limited lesion involving one lateral half of the 



534 



DISEASES OF THE SPINAL CORD. 



Fig. G3. 



cord would be profound anaesthesia of the opposite side of the body 
and a slight degree on the same side. Accordingly, in such cases as 
those I have referred to, there is always a trace of numbness on the 
side the motion of which is paralyzed. The action of a lesion of one 
lateral half of the cord in only slightly diminishing sensibility on the 

side of the alteration while greatly 
lessening it on the opposite side 
will be readily understood from an 
examination of Fig. G5 : a, the left 
half of the spinal cord, b the right 
half ; c, a right posterior root, with 
its ascending fibres cl, its descend- 
ing 6, and its decussating fibres f ; 
r \ ky \} \ | e 9, decussating fibres from the op- 

m fF* m r ■■■"■^| posite side. A lesion of the right 
I side of the cord at h will produce 
great loss of sensibility on the op- 
posite side, and slight loss,on the 
same side. 

With this brief statement of the 
physiology and pathology of the 
subject, I leave the further consideration of the diseases of the poste- 
rior tract of gray matter till science has given us more definite in- 
formation than we now possess relative to its functions and de- 
rangements. 




IV. 



INFLAMMATION OF THE ANTERIOR AND POSTERIOR TRACTS OF GRAY 
MATTER OF THE SPINAL CORD. 

The gray matter of the spinal cord as a whole, is subject to at least 
one disease — tetanus — which, according to recent investigations, is in 
reality a central myelitis. Since Lockhart Clarke in 1864 gave the re- 
sults of his examinations on this subject, other data t to a like effect have 
been published, and, though differences in the lesions have been observed 
these are of secondary importance to the main fact that in tetanus the 
central gray matter is the chief seat of the alterations. The circum- 
stance that the white matter has also been found diseased no more in- 
validates the correctness of the statement than the fact that a patient 
dying with the symptoms of pneumonia, still has that disease, even 
though there be a patch or two of inflamed pleura as a secondary 
lesion. 

a. Tetanus. 

Two varieties of tetanus are generally described by systematic 
writers — the idiopathic and the traumatic; but, as they are character- 



TETANUS. 535 

ized by similar phenomena, differing mainly as to their modes of 
origination and severity of their symptoms, there would be no advan- 
tage in eonsidering them separately. 

Symptoms. — The first symptom to make its appearance in cases of 
tetanus is a feeling of pain or oppression in the epigastric region. In 
the beginning it does not attract much attention, but, as the disease 
advances, it becomes exceedingly severe, and adds greatly to the dis- 
comfort of the patient. 

Soon after the occurrence of this pain uneasiness is generallv ob- 
served about the throat. This is, perhaps, no more than a sense of 
stiffness of the muscles concerned in deglutition, but it is not long 
before swallowing is impeded to a considerable extent. With these 
symptoms there are ordinarily mental and physical depression, sensa- 
tions of chilliness, and a general feeling of malaise. 

The foregoing constitute a prodromatic or formative stage, which 
may last a few hours or several days, and which is occasionally over- 
looked when the disease is intense and rapid in character. 

In the next stage the epigastric j:>ain is still a j^rominent symptom. 
It is seated just below the sternum, and generally extends backward to 
the spinal column. It appears to be due to spasm of the diaphragm, so 
that this muscle is among the first, if not the very first, to be affected 
in the vast majority of cases. The difficulty of swallowing increases, 
and then the muscles of the jaws become contracted, constituting the 
condition known as trismus or lockjaw. At first there is only stiffness 
of these muscles with those of the neck, but gradually they become 
rigid, and the patient experiences difficulty, if not impossibility, in 
opening the mouth. The facial muscles do not escape, and an expres- 
sion like the risus sardonicus is produced from the retraction of the 
angles of the mouth, the elevation of the alae nasi, and the expansion 
of the nostrils. At the same time the eyes are staring, the brows cor- 
rugated, and the countenance anxious or wearied in appearance. 

Sometimes gradually, at others suddenly, the morbid action extends 
to other muscles. Generally it passes to those of the neck, the back, 
and the loins, causing violent contraction, and bending the body back- 
ward. This state is called opisthotonos. The contraction of the power- 
ful muscles referred to is so great as to cause the body to assume the 
form of an arch, the head being thrown far back, the abdomen pro- 
truded, and thus, if the patient were placed on his back, only the 
occiput and heels would touch the bed. Opisthotonos is the usual va- 
riety of spasm. 

Two other forms are occasionally met with. In one of these — em- 
prosthotonos — the body is bent forward from the contraction of the 
thoracic, abdominal, and pelvic muscles. In the other — pleurosthotonos — 
it is bent laterally. This latter may be met with in opisthotonos, owing 
to the muscles on one side being more strongly affected than on the 



536 DISEASES OF THE SPINAL CORD. 

other. Both emprosthotonos and pleurosthotonos are rare. Of very- 
many cases of tetanus that have been under my observation, I have 
only seen the former four and the latter three times. The spasms 
characteristic of the disease are tonic ; but, though they do not 
entirely relax, they are marked by more or less exacerbation, accord- 
ing to the severity of the attack and the care taken of the patient. 
Any cause calculated to excite reflex action will induce an acces- 
sion. Thus the contact of the bedclothes with the body — the legs 
especially — the touch of the hand, the forcible shutting of a door, the 
rumbling of carriages in the street, even the blowing of a breath of 
air on the skin, may produce an aggravation of the spasm. Even 
without any apparent excitation these fits occur. They are marked 
by great pain, and may be so violent as to break the teeth, and the 
bones of the legs, and tear the large muscles of the thigh. During 
their continuance, and often when they are not present, the pain at 
the pit of the stomach becomes unendurable, and the patient may 
lose consciousness through its intensity. I have several times seen 
this event occur. 

The tonic rigidity of the muscles of respiration induces diffi- 
culty of breathing, and the same result may ensue from spasmodic 
closure of the glottis. Death has frequently taken place suddenly 
from one or other of these causes. With all this muscular excite- 
ment and mental disturbance there is in the early stages rarely any 
fever. Toward the close, however, the skin is hot, and the ther- 
mometer often ranges from 105° to 110° Fahr., or even higher, but 
the pulse remains small and weak. 

Owing to the difficulty of swallowing, the patient suffers from hun- 
ger and thirst, and thus the powers of the system are still further re- 
duced. The bowels are always obstinately constipated. 

Wakefulness is generally present from the first. When the patient 
does sleep, it usually happens that the muscles are relaxed, to be again 
suddenly affected with spasm as soon as he awakes. 

The mind is clear throughout, even in the most severe cases. When 
loss of consciousness occurs from extreme pain, it is from syncope, and 
not from any implication of the brain in the essential nature of the 
disease. Death usually takes place by apncea. It may, however, re- 
sult from exhaustion, and, according to some authorities, from the 
spasmodic action attacking the heart. 

The duration of the disease is very variable. The shortest case on 
record is one observed by Prof. Robinson, of Edinburgh. The patient, 
a negro waiter, cut his finger with a piece of broken china. He was 
immediately seized with tetanus, and died within fifteen minutes. Mr. 
Poland quotes a case in which death took place in five hours ; in a case 
cited by Lepelletier in a few hours ; in one by Dr. Jackson in twelve ; 
in one by Dr. Leith in eighteen ; and in one observed by Mr. Curling 



TETANUS. 



537 



in nineteen. 1 The shortest duration in any case I have witnessed was 
twenty-six hours, though I believe there were several much shorter, 
which occurred during the recent war in this country. 

The average period of duration in fatal cases is from the third to 
the fifth day. Instances in which it has been prolonged far beyond 
this limit are not uncommon. Hennen 2 reports a case in which it 
lasted six weeks, and then the patient died of another disease. He 
reports another case in which it lasted seven weeks, and ended in 
recovery. I have seen three cases in which it extended to the fifth 
week. 

The period which elapses between the reception of the cause and 
the beginning of the symptoms is also subject to a great variation. 
In a case already cited it was only fifteen minutes ; in another, quoted 
from Dr. Randolph by Reeves, 3 the spasms ensued immediately after 
the patient was stung by a bee ; and in another, which occurred in 
his own experience, they came on in a sensitive female immediately 
after running a needle into her finger. There is doubt, however, 
as to such cases really being tetanus. In the last one cited it is 
stated that " the body and extremities were rigid, mouth closed, and 
the jaws fixed, the eyes the same. At short intervals the whole 
body was affected with convulsive shocks ; the administration of a 
dose of chloroform removed them, but the back and neck remained 
rigid for three days." This attack was probably a manifestation of 
hysteria. 

In eighty-one cases collected by Mr. Curling, the disease began 
between the fourth and fourteenth days, both inclusive, and in nine- 
teen on the tenth day. 

The following table from Reeves shows the period of the occur- 
rence of the disease in three hundred and fortv-three cases : 



Within 6, 12, IS, or 24 hours 12 

From 1 to 2 days 12 

" 3 " 5 " 37 

" G " 8 " 94 

" 9 " 12 " 77 

" 12 " 14 " 52 



From 15 to 17 clays 



25 



IS " 20 


u 


9 


21 " 23 


u 


9 


24 " 26 


it 


6 


27 " 29 


a 


9 


30 " 32 


u 


1 



Causes. — The microbic origin of many cases of tetanus seems to 
be beyond dispute. It is claimed by many, and perhaps with a great 
deal of reason, that all cases of tetanus, whether traumatic or idio- 
pathic, are due to the presence in the system of the tetanus bacilli. 
The power of this microbe to induce tetanus was first successfully 

1 All the above instances are quoted from Reeves's " Diseases of the Spinal Co^d 
and its Membranes," London, 1S58, p. 387 ct seq. 

2 " Observations on some Important Points in the Practice of Military Surgery," etc., 
Edinburgh, 1818, p. 263. 

3 Op. cit, p. 377. 



538 DISEASES OF THE SPINAL CORD. 

demonstrated by Rosenbach 1 in 1886, and confirmed later by Hoch- 
singer, 2 Yanni and Garri, 3 Bonome, 4 and others. Bonome describes 
the bacillus as " slender and bristle-like, with a small colorless swell- 
ing at each end like the head of a pin." This bacillus had previously 
been described by Nicolaier 5 in connection with cases of tetanus. 
Pus containing these bacilli, w T heri injected into the muscles or be- 
neath the skin of an animal, invariably induced tetanus, but when 
injected into the blood failed to do so. Hochsinger, 6 however, in a 
later article on this subject, claims to have discovered that although 
the tetanus bacilli is not found in the human blood in subjects suffer- 
ing from tetanus, yet the blood possesses poisonous qualities, and, 
when injected into animals, invariably induced tetanus. The tetanus 
microbe is found in the earth, and, according to Bonome, in the dust 
and mortar of old buildings. It is only necessary for the microbe to 
be deposited in some open wound, or to be introduced into the sys- 
tem in some other manner, in order that tetanus should be developed. 
According to this theory, tetanus cannot be considered as traumatis- 
mal in the proper sense of the word, the wound simply being the 
means of the introduction of the tetanus microbe into the system. 

The most common cause of tetanic infection is bodily injury of 
any kind, from the slightest to the most severe, and of any part 
of the body; although wounds of some parts, as of the thumb and 
great-toe, are more apt to be followed by the disease than those of 
other regions. It has been known to result from the bite of a tame 
sparrow, from the sticking of a small fish-bone in the pharynx, from 
a seton in the thorax, from the stroke of a cane across the back of 
the neck, from the blow of a whip-lash, from fractured bones, and 
from every other imaginable wound or injury. In a case under my 
charge in this city, it was caused by a, splinter of wood slightly 
scratching the palm of the hand ; in another, a slight punctured 
wound of the foot produced it. 

Next in frequency to wounds, tetanus is induced by exposure to 
cold and damp. This is the exciting cause in the majority of cases of 
idiopathic tetanus, and it increases liability in those who have suffered 
from wounds. It was not uncommon, during the recent war, for the 
number of cases of tetanus to be much increased immediately after a 
sudden change of the weather from dry and mild to wet and cold. 

It has also apparently been caused by worms, by abortion and labor, 
and by diseases of the womb. Terror has the reputation of having in- 

1 Archiv fur Min. Chir., Berlin, 1886-'87, xxxiw, p. 306. 

2 Centralblatt fur Bacteriol. tind Parasitenk., Jena, 1887, x., p. 1068. 

3 Sperimentale, Firenze, 1887, lix., p. 617. 

4 Gior di R. Acad, di Med. di Torino, 1886, 3d S., xxxiv., p. 759. 

5 "Beitrage zur Aetiologie des Wundstarrkrampfe," Gottingen, 1885. 

6 Fortschriit der Med., February 5, 1888. 



TETANUS. 539 

duced tetanus in one case reported by Dr. Willan, and in others ob- 
served by Hennen. 

In the form occurring in very young children, and known as tris- 
mus nascentium, it appears to be induced by inattention to the cut um- 
bilical cord. 

The tendency to tetanus, especially among soldiers and others who 
have been wounded, is increased by poor diet, confinement in ill-venti- 
lated hospitals, inattention to cleanliness, and neglect to give proper 
care to the wounds they may have received. 

Diagnosis. — The only affections with which tetanus is liable to be 
confounded, by any but the most ignorant, are the hysterical simulated 
affection, and the condition induced by poisoning with strychnia and 
other substances of its class. 

That hysteria can simulate tetanus, as well as almost all other dis- 
eases, we have abundant evidence. A case has already been referred 
to in this chapter which was evidently hysterical, and several others 
have come under my observation. A lady now under my charge has 
repeated attacks of hysterical spasms, during which her jaws are tight- 
ly closed, she is unable to swallow, and her body is bent backward so 
as to assume the position of opisthotonos. 

Such seizures are readily distinguished from tetanus by the facts 
that they are unaccompanied by pain or real distress, are of very tran- 
sient duration, and are accompanied by other manifestations of hys- 
teria. 

From the artificial tetanus caused by strychnia, the diagnosis is 
more difficult; for, so far as the more obvious symptoms go, there is 
such a great similarity that even the most skillful diagnosticians might 
be, for a time, undecided. It is well known that strychnia is not unfre- 
quently used for the purpose of committing murder or suicide, and it is 
possible so to employ it for either of these purposes as to cause its 
effects to extend over a long period of time, and thus to add to the 
difficulties attending the discrimination. Even in such a case, however, 
the diagnosis can be made if due care and a thorough inquiry into the 
history of the case be made. 

In the first place, the tetanus of strychnia always shows itself in 
the lower extremities before trismus ensues. The legs are stretched 
widely apart, and the hands are generalty involved. In natural tetanus, 
trismus precedes spasm in the extremities; indeed, the lower extremi- 
ties are rarely affected to any great extent. The arms generally escape 
altogether. 

The epigastric pain, which constitutes so prominent a feature of 
true tetanus, is not present in the toxic variety. I have witnessed 
three cases of poisoning by strychnia, and this pain was not complained 
of in either of them. 

In the tetanus of strychnia, the symptoms are developed with great 



540 DISEASES OF TIIE SPINAL CORD. 

rapidity, and death takes place generally within a half an hour, al- 
though life may be prolonged, in exceptional cases, somewhat beyond 
this period. In true tetanus it is very rarely the case that death takes 
place within twelve hours, and ordinarily not till several days have 
elapsed. 

In those cases of poisoning by strychnia in which the doses have 
been small, and administered at comparatively long intervals, the symp- 
toms are mitigated in violence, and consequently one of the distinguish- 
ing features of the two affections is lost. Still, the general character 
and sequence of the phenomenon are the same, and it is not improbable 
that careful observation and inquiry will fail to elicit the true nature of 
the case. 

Prognosis. — The longer the time that has elapsed between the recep- 
tion of the injury or subjection to other cause, the greater is the prob- 
ability of a favorable termination. When the paroxysms are slight, and 
the intervals between them long, the prognosis is also more favorable. 
A low bodily temperature is a favorable indication. On the contrary, 
an elevated temperature is of fatal augury. The duration of the dis- 
ease is likewise an important element in the prognosis; and, when it 
has lasted over a week, death does not often take place. Cases are, 
however, on record in which a fatal result has supervened after the 
affection has existed for several weeks. 

Tetanus is, nevertheless, one of the most fatal of maladies. Dr. 
O'Beirne ' witnessed two hundred cases without a single recovery. 
Hennen 2 never saw a case of acute symptomatic tetanus recover. 
McLeod 3 has collected and analyzed twenty-three cases which occurred 
in the British army in the Crimea, of which but two recovered. Demme 4 
refers to eighty-six cases in the hospitals in Italy during the campaign 
of 1859, of which six were cured ; and Hamilton B has observed eight 
cases, of which three recovered. 

Nine cases have been under my immediate care, of which there were 
three recoveries. Of the many cases which I observed in the course of 
my inspections of camps and hospitals in the army during the recent 
war, I do not know how many terminated favorably. I am disposed, 
however, to believe that the number was not great. Hamilton states 
that his information leads him to think that, of one hundred and fifty 
cases which occurred during the war, the recoveries were few. 

Morbid Anatomy and Pathology. — As regards the cord, the results 
of post-mortem examination of patients who have died of tetanus have 

1 " Dublin Hospital Reports," vol. iii., pp. 343, 378. 

2 Op. cit., p. 262. 

3 " Notes on the Surgery of the War in the Crimea," London, 1858, p. 153, et scq. 
Also table, p. 439. 

4 " Militar-chirurgische Studien," Wiirzburg, 1861. 

6 "A Treatise on Military Surgery and Hygiene," New York, 1866, p. 595. 



TETANUS. 541 

rip to a comparatively late period been very unsatisfactory. Roki- 
tansky, 1 in chronic cases, found a proliferation of connective tissue. 
Wedl, 2 in one case, discovered increased redness of a portion of the 
spinal cord. Curling 3 declared that serous effusion with increased vas- 
cularity was generally observed in the membranes investing the medulla 
spinalis, and also a turgid state of the blood-vessels above the origin of 
the nerves ; and Wunderlich 4 regarded the lesions as consisting in a 
proliferation of the connective tissue of the cord, the medulla oblongata, 
and the cornua cerebri and cerebelli. 

But, in 1864, Dr. Lockhart Clarke, 5 after a careful examination of 
the spinal cords of six persons who had died of tetanus, found as the 
uniform results an abnormally enlarged condition of the blood-vessels 
throughout the gray matter, especially in the posterior horns, and 
granular disintegration of the nerve tissue. He expresses the opinion 
that tetanus depends (first) upon an excessively excitable state of the 
gray nerve tissue of the cord induced by the hyperemia, and morbid 
condition of the blood-vessels, and the exudation and disintegration 
resulting therefrom, and (second) that the spasms are the result of the 
persistent irritation of the peripheral nerves by which the exalted 
excitability of the cord is aroused, and thus the cause which at first 
induced in the cord its morbid susceptibility to reflex action is subse- 
quently the source of that irritation by which the reflex action is 
excited. 

Subsequently, Dickinson e found enlargement of the blood-vessels 
throughout the gray substance of the cord, with perivascular exuda- 
tion, rupture of the blood-vessels in many places, and granular disin- 
tegration. 

Dr. Clifford Allbutt T has reported the results of his examination of 
the spinal cords in four cases of tetanus. He found diminution of the 
consistence of the cord of various degrees and situation ; haemorrhage 
in two cases visible to the naked eye ; enlargement of the blood-vessels ; 
exudation of a granular plasma surrounding the vessels ; enlargement 
of the cells of the gray matter, and the granular degeneration of 
Clarke. Outside of this cord he found the nerve thickened and con- 

1 " Beitrage zur Pathologie des Tetanus," Virchovfs Archiv, tome xxvi., 1862. 
8 " Rudiments of Pathological Histology," " Sydenham Society Translation," London,, 
1855, p. 276. 

3 "A Treatise on Tetanus," etc., London, 1836. 

4 Archiv der Heilkunde, 1862. 

6 Lancet, 1864; Medical Times and Gazette, 1865; also, more fully, "On the 
Pathology of Tetanus," Medico-Chirurgical Transactions, vol. xlviii., 1865, p. 255. 

6 "Description of the Spinal Cord in a Case of Tetanus," Medico-Chirurgical Trans. 
actions, vol. li., 1868, p. 267. 

7 " On the Changes of the Spinal Cord in Tetanus," " Transactions of the Patho- 
logical Society of London," vol. xxii., 1871, p. 27. 



542 DISEASES OF THE SPINAL CORD. 

gested, and bathed in inflammatory products. These results were con- 
firmed by the subsequent examination of Drs. Clark and Dickinson. 

Dr. Fox ' made post-mortem examinations of four cases. In one 
the only abnormality remarked was dilatation and distention of the 
vessels of the spinal pia mater. In the others there were softening, 
haemorrhage, amyloid bodies, in the gray substance, and thickening of 
the vessels. 

Michaud 2 examined the cord in four cases. He found that the gray 
matter presented a general red appearance. The vessels were enor- 
mously enlarged. There were numerous free nuclei and foci of perivas- 
cular exudation. The gray substance, and especially the posterior 
commissure, was the seat of these alterations which, according to him, 
consist essentially in a proliferation of the nuclear elements of the con- 
nective tissue. The appearance which Lockhart Clarke considers to be 
a granular degeneration, Michaud regards as being due to these nuclei 
existing in the exudation around the blood-vessels. He considers teta- 
nus to be an acute inflammation of the gray tissue of the cord. 

When either of the upper extremities is the seat of the wound, 
which is the primary cause of the disease, the lesions of the cord are 
found in the cervical enlargement, and, when either of the lower limbs 
is injured so as to induce the affection in question, the spinal lesions 
are found in the lumbar enlargement. 

The nerves coming from the wounded part have been found the 
seat of inflammation by Airlong and Tripier, 8 and by Michaud. In 
other cases they have not exhibited any change. 

The muscles of the body suffer secondarily. The violent spasmodic 
contractions to which they are subjected often produce ruptures of their 
tissue and extravasations of blood. 

On the other hand, it has often happened, especially in very rapid 
cases, that nothing has been found which could fairly be regarded as 
constituting the essential feature of the disease. Billroth B affirms that 
his examinations of the spine and nerves, in cases of tetanus, have thus 
far given only negative results, and this is in accordance with the ob- 
servations of the great majority of pathologists. But these discrepan- 
cies are, I think, to be ascribed to defective methods of examination, 
and in no event can they disprove the positive data obtained by others. 

It is contended by some authors that tetanus, like hydrophobia, is 
due to blood-poisoning. The fact, that a condition, so nearly resem- 
bling it as to be with difficulty diagnosticated from it, may be caused 

1 " Recherches anatomo-pathologiques sur l'etat dee systemes nerveux central et peri* 
pherique dans le tetanus traumatique," Archives de Physiologie, 1871, p. 59. 

2 " The Pathological Anatomy of the Nervous Centres," London, 18*74, p. 355. 

3 Archives de Physiologie y 187<~>, p. 244. 

4 Op. cit. 

6 " General Surgical Pathology and Therapeutics, in Fifty Lectures," Hackley'a 
translation, New York, D. Applecon & Co., 1871, p. 353. 



TETANUS. 543 

by the injection of strychnia into the blood, appears to favor this view. 
However this may be, the character of the symptoms, as well as the 
anatomical lesions, indicates the spinal cord to be the seat of the 
disease. 

The first symptoms of tetanus — spasm of the diaphragm and tris- 
mus — indicate that the initial disturbance in the spinal cord is to be 
found at as high a level in the cerebro-spinal system as the nucleus of 
the fifth nerve. The increase in temperature may be accounted for 
by the implication of the heat-producing centre which Ott ] has shown 
exists in the pons. 

The spinal cord is both an organ for the generation of nerve-force, 
and for conducting impressions to and from the brain. In tetanus it 
is this first-named function which is deranged, and this is shown by 
the great exaltation of reflex excitability which exists. Everything 
capable of causing a reflex movement of the slightest kind, and even 
excitations which in health would be altogether unperceived by the 
cord, augments its intrinsic action to a great extent where tetanus exists. 

Now, we are able to, produce a similar increase of reflex action by 
strychnia ; and, in those cases of disease in which the amount of blood 
in the cord is increased, very small quantities of strychnia produce the 
characteristic phenomena of stiffness in certain muscles, and of aug- 
mented reflex excitability. The condition is aggravated by the medi- 
cine ; and, if we had no other facts to support the theory, we should 
be warranted in concluding that, in cases of strychnia-poisoning, the 
amount of blood in the cord and the excitability of the organ are both 
increased. From a consideration of all the points bearing on the sub- 
ject, we are warranted in concluding that tetanus essentially consists 
in a morbid exaltation of the functions of the spinal cord as a nerve- 
centre. 

Bernard 2 has investigated this matter with his usual exactness. He 
says : " Strychnia produces convulsions by exaggerating the sensibility 
of certain parts ; it also causes reflex movements. We have seen that 
the point of departure is in the sensitive system ; for, where the pos- 
terior roots of the nerves are cut, the animal dies without convulsions." 

An experiment performed by myself and my friend and collabora- 
tor, Dr. S. Weir Mitchell, 3 shows that the action of strychnia is to 
destroy the nervous excitability from the centre to the periphery. Its 
influence, therefore, must first be exerted on the spinal cord. 

1 " The Heat-Centres of the Cortex Cerebri and Pons Varolii," Journ. Kerv. and 
Ment. Bis., February, 1888. 

2 " Lecons sur les effets des substances toxiques et medicamenteuses," Paris, 185*7, 
p. 386. 

3 " Experimental Researches relative to Corroval and Vao ; Two New Varieties of 
Woorara, the South American Arrow-Poison," American Journal of the Medical Sciences, 
July, 1859 ; also " Physiological Memoirs," Philadelphia, 1863, p. 181, et seq. 



544 DISEASES OF THE SPINAL COED. 

" Under the skin of a large frog, whose left sciatic nerve was pre- 
viously divided, a few drops of a strong solution of strychnia were in- 
troduced. Tetanic spasms ensued in two minutes. After forty-five 
minutes the nerves were irritated by galvanism. That of the left side, 
which had been cut, responded, energetically, while no motions could 
be produced through the uncut nerve. The former remained excitable 
for two hours later." 

Bernard ' asserts that the action of strychnia extends no farthei 
than the spinal cord ; and any one who has seen a frog under the influ- 
ence of this substance cannot have failed to notice that all the symp- 
toms indicate exalted spinal action. 

We are tnerefore led by observation and experiment to the conclu- 
sion that the lesion of tetanus is seated in the gray matter of the 
spinal cord, and that, although we cannot at present affirm an absolute 
identity of the lesions, in each case we have enough data to enable us 
to say in general terms that tetanus is essentially an inflammatory 
affection of the gray matter of the spinal cord. 

Vulpian 3 has shown that strychnia does not produce organic lesions 
of the cord. He kept a frog for a month under its influence, and on kill- 
ing the animal found the cord in all its parts in a perfect state of integ- 
rity. But on this point there is a difference of opinion, Jacubowitsch 
and Roudanowsky asserting that the processes of the nerve-cells are 
torn, and that the cells themselves are often ruptured. It is not, how- 
ever, probable that the condition of the cord, in poisoning by strychnia, 
ever goes beyond the point of hypersemia, which, being of recent oc- 
currence, would disappear on death supervening. It is also extremely 
probable that, in the cases of tetanus in which recovery takes place, the 
organic derangements discovered by Lockhart Clarke do not occur. 
This is his opinion : Hyperemia is the first stage of all inflammations, 
and it is of course entirely possible that the morbid process should be 
aborted at this stage. Indeed, it is a matter almost of certainty that in 
some fatal cases of tetanus the pathological action has not gone beyond 
the hyperasmic stage, and hence the absence of lesions in the cases ex- 
amined by Billroth and others. But a hyperemia of this kind is of 
course as much of the nature of inflammation as though the process 
had reached its full development. 

How does a wound of the extremity or trunk of a nerve cause tet- 
anus ? It has been supposed by some authors that there was a neuri- 
tis in each case which advanced centripetally till it reached the spinal 
cord. In regard to this point, Mitchell 3 says : 

" There is a prevalent belief that tetanus is more apt to arise when 

1 Op. cit., p. 359. 

2 " Convulsions pendant un mois chez une grenouille ernpoisonee par la strychnia ; in- 
tegrity complete de la mobile epiniere," Archives de Physiologic, 1868, p. 306. 

3 " Injuries of Nerves and their Consequences," Philadelphia, 1872, p. 147. 



TETANUS. 545 

laro-e nerves are slightly hurt than on other occasions ; but, although 
there are on record many cases where this terrible malady has followed 
the inclusion of nerves in ligatures, in the mass of tetanic histories the 
causal irritation has arisen in the extreme distribution of nerves, and 
where there has been no proof of precedent injury to large trunks. 
Were it otherwise, I must more often have seen tetanus, whereas, in 
two hundred recorded instances of wounds of great nerves which passed 
under my eye during the war, not a single case of lock-jaw was seen, 
although in perhaps one-half, the injuries were recent, and we actually 
witnessed a part of the process of healing. In fact, the tendency tow- 
ard irritation resulting in spasm seems to increase as the nerves divide 
and approach the skin. Brown-Sequard succeeded once in causing te- 
tanus by leaving a rusty tack in the foot of an animal. I have never 
been able to get this result by any method, nor, in some seventy sec- 
tions or wounds of nerves in animals, have I ever encountered it." 

The experience of Dr. Mitchell on this point is sufficient to deter- 
mine it against the existence of a neuritis extending to the cord. Were 
there any such cause it would undoubtedly be more apt to arise from a 
wound of the trunk of a nerve and to extend to the cord, than from an 
injury of the terminal extremities. Moreover, the facts that tetanus has 
been known to follow in a few minutes after the reception of a wound, 
and that there is no pain along the course of the nerve, are directly at 
variance with the idea of a peripheral and ascending neuritis as the 
cause of the spinal lesions. 

Treatment. — There is scarcely a sedative or stimulant remedy in the 
pharmacopoeia which has not been employed and recommended in teta- 
nus. Aconite, ether, belladonna, chloroform, cannabis Indica, conium, 
opium, tobacco, Calabar bean, ice, counter-irritants, alcohol, and many 
other substances, have been used, and cases reported which have appar- 
ently recovered under their administration. Then, of surgical means, 
excision of the injured nerve and amputation of the wounded member 
have also been recommended, but are not, I believe, practised now. 
Latterly the bromide of potassium and hydrate of chloral have been 
employed with favorable results. 

A case in which the latter agent was successfully used in tetanus is 
reported by Dr. Wirth, 1 of Columbus, Ohio. In about a month the pa- 
tient took nine ounces and two drachms, in doses of from thirty to forty 
grains, at times as often as every one and a half hour. In this case 
opium in large doses had been administered without effect. A number 
of other cases, in which chloral was administered, are cited in the same 
Dumber of the New York Medical Journal in which Dr. Wirth's case 
appears, in several of which it was successful. 

A very thorough analysis by my friend Dr. D. W. Yandell, 2 of Louis- 

1 New York Medical Journal, November, 1870, p. 419. 

2 American Practitioner, September, 1870, p. 152. 

36 



546 DISEASES OF THE SPINAL CORD. 

ville, of an unpublished report on tetanus, by Dr. R. O. Cowling, em- 
braces so much valuable information on the subject that I quote the 
summary entire. The term acute is applied to tetanus occurring within 
nine days of the injury, and chronic to cases ensuing after nine days : 

" Calabar bea?i was given in thirty-nine cases, with thirty -nine per 
cent, of recoveries. Of these reported cures, but one was of acute teta- 
nus ; five others w r ere in cases which recovered before the expiration of 
fourteen days. Per contra, there were ten deaths from chronic tetanus. 

" Indian hemp used in twenty-five cases, with sixty-four per cent, 
of recoveries, of which three cases were acute, and six recovered before 
the symptoms lasted fourteen days. 

" Chloroform relieved seventy per cent, of thirty-five cases, nine of 
which were acute, and eight recovered before fourteen days. Three 
chronic cases died, and two after symptoms lasted fourteen days. 

" Ether. — Sixty per cent, of fifteen cases recovered ; five acute ; 
seven inside of fourteen days. One chronic case died. 

" Opium. — Fifty-seven per cent, of one hundred and sixty -five cases 
recovered ; twenty-two acute ; twenty-nine before the fourteenth day. 
Twenty-six chronic cases were lost, and four after the disease had con- 
tinued fourteen days. 

" Tobacco relieved fifty per cent, of forty-one cases ; six acute ; six 
before fourteen days of the disease. Four chronic cases died, and one 
after fourteen days. 

" Quinine. — Seventy-three per cent, of fifteen cases recovered ; one 
acute ; three before fourteen days. Three chronic cases ended fatally, 
and one after fourteen days' duration. 

" Aconite. — Eight per cent, of fourteen cases recovered ; none acute ; 
none recovered before fourteen days. Death in one chronic case. 

" Stimulants. — Eighty per cent, of thirty -three cases recovered ; 
four acute ; six within fourteen days. Six chronic cases died, and 
three after fourteen days. 

" Mercury. — Fifty -seven per cent, of seventy-five cases got well ; 
twelve before fourteen days. Seventeen chronic cases were lost, and 
two after fourteen days. 

" Bleeding. — Fifty-five per cent, of fifty-eight cases recovered ; nine 
acute ; ten before the fourteenth day. Seven chronic cases were lost, 
and two after fourteen days. 

" Cold Affusion. — Seventy-three per cent, of eleven cases recov- 
ered ; three acute ; three before fourteen days. Two chronic cases 
died. 

" Ice-bags. — Seventy-seven per cent, of nine cases recovered ; one 
acute ; two in less than fourteen days. 

" Amputation. — Sixty per cent, of seventeen cases recovered ; four 
acute ; four in less than fourteen days. Three chronic cases died, and 
one after fourteen days. 



TETANUS. 547 

"Division of nerve relieved seventy-five per cent, of three eases; 
one acute ; one before the fourteenth day. One chronic case died. 

"Purgatives. — Sixty-six per cent, of seventy-four cases recovered ; 
thirteen acute ; twelve before fourteen days. Ten chronic cases died, 
and three after fourteen days. 

" Turpentine relieved seventy per cent, of sixteen cases ; six acute; 
four before fourteen days. Five chronic cases died, and two after 
fourteen days." 

Among the conclusions arrived at by Dr. Yandell from these data 
are, that " recoveries from traumatic tetanus have been usually in cases 
in which the disease occurs subsequent to nine days after the injury ; 
that when the symptoms last fourteen days recovery is the rule, and 
death the exception, apparently independent of the treatment ; that 
chloroform, up to this time, has yielded the largest percentage of cures 
in acute tetanus ; that the true test of a remedy for tetanus is its influ- 
ence on the history of the disease : does it cure cases in which the dis- 
ease has set in previous to the ninth day ? does it fail in cases whose 
duration exceeds fourteen days ? and that no agent, tried by these tests, 
has yet established its claims as a true remedy for tetanus." 

It is, perhaps, scarcely necessary to say that I fully accord with 
these opinions. 

Judging from its effects upon the spinal cord, it was supposed by 
Mr. Morgan that woorara injected into the blood might prove efficacious 
in tetanus. Experience, however, has not confirmed this view ; and the 
researches of Dr. Cowling show that it is one of the most inefficient of 
remedies. 

In a case which was under my charge fifteen years ago, when I was 
one of the surgeons of the Baltimore Infirmary, I injected corroval — a 
remedy which the investigations of Dr. Mitchell and myself had proved 
to be antagonistic to strychnia — into the blood. The patient, a colored 
bo»y, became affected with tetanus two days after his arm had been am- 
putated by my friend and colleague Prof. Nathan R. Smith. Cannabis 
Indica, morphia, and chloroform, had been used without effect, when at 
my request Prof. Smith turned the case over to me, in order that cor- 
roval might be administered. Two drops of a strong solution of the 
substance in water were injected into the cellular tissue of the forearm. 
At the time the pulse was 160, and the respirations about 75. There 
was very decided opisthotonos. In three minutes the pulse had fallen 
to 152. Two more drops were then injected, and the pulse fell to 144. 
As it soon rose again, two more drops were injected, when it fell to 
132, and the respirations to 64. The spasms still continuing, two more 
drops were injected. In five minutes the pulse began to decline rap- 
idly, and in ten minutes had fallen to 90. At this time the patient had 
a violent tetanic spasm, and during its continuance the pulse became 
intermittent. It then rapidly went down to 40, then to 30, and during 



548 DISEASES OF THE SPINAL CORD. 

a violent spasm the patient died. From this record it will be seen that 
at no time did the corroval exercise the least effect over the disease. 1 

As I have stated, three successful cases have occurred in my prac- 
tice. One of these I saw in consultation with Dr. J. Lewis Smith, of 
this city. It was traumatic, and had ensued two weeks after a wound 
of the foot by a nail. The patient was treated by cannabis Indica, and 
the persistent application of ice to the spine. The spasms were greatly 
lessened in force and frequency, and recovery took place within two 
weeks. Another, which was also traumatic and acute — that is, making 
its appearance within nine days after the injury — was treated accord- 
ing to the same plan, and recovered in sixteen days, though the jaws 
remained stiff for several weeks afterward. The wound was caused by 
an ice-pick being accidentally thrust through the hand. The third case 
was that of an eminent musician of this city, who, while drilling with 
the regiment to which he belonged, injured his thumb with a splinter 
from the stock of his rifle. The first evidence of tetanus appeared on 
the twelfth day. The attack was not very severe. I administered the 
extract of cannabis Indica (Squires's) in doses of half a grain every two 
hours, and kept up the application of ice to the spine continuously for 
six days. There were several violent spasms during this period, and 
the opisthotonos was well marked. At the end of a week the cannabis 
Indica was omitted for a day, but, the spasms becoming more frequent 
and severe, it was resumed as before, and continued with tolerable regu- 
larity for ten days longer. During this period there were but two 
spasms, and the opisthotonos became less. It was then gradually di- 
minished, and on the twenty-fifth day was left off altogether, the patient 
being convalescent. 

I am disposed to think that, whatever internal medication be adopt- 
ed, the application of ice to the spine is a measure which should always 
form a feature of the treatment. 



IV. 

INFLAMMATION OF THE ANTERIOR COLUMNS OF THE SPINAL CORD 
(SCLEROSIS OF THB COLUMNS of turck). 

Txirck 2 has shown that the anterior columns of the spinal cord are 
subject to a chronic inflammation such as is now known under the name 
of sclerosis. In the cases which he described the morbid process in- 

1 " Traumatic Tetanus; Inoculation with Corroval; Death," by Edward Milholland, 
M. D., Resident Physician at the Baltimore Infirmary. In Maryland and Virginia Medi- 
cal Journal, January, 1861, p. 13. • 

2 " Ueber Degeneration einzelner Riickenmarksstrange, welche sich ohne primare 
Krankheit des Gehirnes oder Riickenmarks entwickelt," Sitzungsberichte der kaiserlichen 
Academie der Wissenschaften, Mat. nat. CI., 1856, p. 112. 



INFLAMMATION OF THE LATERAL COLUMNS. 549 

volved symmetrically a small region on each side of the anterior me- 
dian fissure— that part which is designated the column of Turck. 
Microscopical examination showed proliferation of the neuroglia, with 
degeneration of the true nerve-elements. 

The course of the disease, the symptoms, causes, etc., together with 
the morbid anatomy and pathology, do not differ essentially from the 
corresponding affection of the lateral or crossed pyramidal tract which 
is more frequent and is more thoroughly understood. Our present 
knowledge leads us to the inference that the columns of Turck are in 
function similar to the lateral columns. The number of cases in which 
they have been found altered is as yet small, and they have not been 
very thoroughly worked up. In some cases they have been sclerosed 
in conjunction with a like condition of the lateral columns. 

I shall, therefore, pass at once to the consideration of the next 
division of the subject. 



INFLAMMATION OF THE LATERAL PYRAMIDAL TRACT OF THE SPINAL 
CORD ; SPASTIC SPINAL PARALYSIS (PRIMARY SYMMETRICAL LAT- 
ERAL SCLEROSIS). 

Turck, 1 who, as we have seen, demonstrated the fact that the ante- 
rior columns of the cord could be the primary seat of sclerosis without 
any other region participating in the lesion, also showed that the lateral 
columns could be similarly affected. Tiirck's investigations were al- 
lowed to remain scarcely noticed for ten years, when Charcot a made 
like observations and since then has aided in establishing it as a dis- 
tinct pathological condition. 

Symptoms. — The chief phenomena of the disease under considera- 
tion are paralysis and contraction of the affected limbs. The lower ex- 
tremities are, more than the upper, liable to be the seat of these symp- 
toms. The loss of power is very gradual, and there is no atrophy be- 
yond the general emaciation consequent upon diminished use of the 
muscles. Sensibility is not in general affected, but in some cases there 
is more or less pain in the paretic lijnbs and in the back near the seat 
of the disease. 

The paralysis is rarely complete. At first the patient merely tires 
more readily, slight exertion fatigues him, and this is especially noticed 
in the muscles which flex the leg upon the thighs, and the consequent 
sensation of weariness is experienced in the popliteal space. Some- 
times it is shown in the sudden relaxation of the extensor muscles of 
the leg and the fall of the patient thereby ; at others, in the fact that 
the extensors of the foot become weak, allowing the toes to drop, 
and hence causing stumbling. The gait then becomes characteristic. 
1 Op. tit., p. 112. 2 V 'Union Medicate, 1855. 



550 DISEASES OF THE SPINAL CORD. 

Owing to the fact that the patient's extensor muscles are weak, he 
is unable to lift the feet high enough to clear the ground, and hence 
he throws them out by means of the abductor muscles of the thigh, and 
thus causes them to describe an arc of a circle. Then in putting them 
down the heel strikes the ground a longer time before the sole than it 
does in the natural gait, and hence the foot comes down with a jerking 
motion. This is the ordinary manner of walking practised by a person 
affected with the disease under notice. In another form of locomotion, 
the body is moved laterally on the thighs, first to one side and then to 
the other, in such a way as to cause the feet to be raised high enough 
without the complete action of the extensor muscles. The gait is there- 
fore similar to that of a duck, or of a woman with a very wide pelvis. 
The motion of the body is almost serpentine, and the feet glide over 
the ground barely lifted high enough to avoid contact. 

In both the methods of walking the patient requires support. At 
first a cane answers, then he comes to crutches, and eventually the as- 
sistance of an attendant becomes necessary. 

As a consequence of the paralysis, and the contractions which event- 
ually ensue, the movements are often complicated and sometimes ren- 
dered impossible by the legs becoming interlocked at every attempt to 
walk. In a patient from Connecticut under my care, not long since, 
this difficulty was a very prominent feature, and though the muscles of 
flexion and extension were sufficiently strong to allow of his walking, 
those which abduct the thighs were so materially paralyzed, and the 
adductors were so greatly contracted, as to produce the condition 
mentioned. 

Reflex movements, so far from being lessened, are generally exalted ; 
and this is especially true of the " tendon reflex," as exhibited when one 
leg is crossed over the other and a smart blow given with the edge of 
the hand over the tendon of the quadriceps extensor, just below the 
patella. The leg is suddenly extended, and bounds much higher than 
it normally does under like excitation. An exaggerated " knee-jerk," 
however, unaccompanied by other symptoms of disease of the lateral 
pyramidal tract, is of no importance whatever. The electrical con- 
tractility of the muscles remains .unimpaired. The "ankle clonus," 
which consists of an alternating spasm and relaxation of the gastroc- 
nemius, can always be obtained, except in some well-advanced cases, 
by supporting the weight of the patient's leg and then, grasping the 
foot firmly, suddenly extending it, when, if the conditions are favor- 
able, the foot will be thrown into rapid vibrations of flexion and ex- 
tension. In some patients who have been afflicted with the disease 
under consideration for a long time the muscles of the leg become so 
stiff and rigid that the ankle clonus cannot be obtained, and even 
the exaggeration of the knee-jerk cannot be demonstrated. 

Sometimes the contractions, which are so prominent a feature, re- 



INFLAMMATION OF THE LATERAL COLUMNS. 551 

lax, but they again supervene, and generally persist with more or less 
intensity till the closing stages of the disease, when the power of the 
cord becoming exhausted entirely, and all the muscles being paralyzed, 
the spasmodic action ceases. 

A very remarkable case is one reported by Charcot, 1 of a woman 
who, after several hysterical attacks, was seized, after having been 
greatly frightened, with a violent paroxysm of hysteria, which was 
soon, followed by a general trembling, accompanied by a weakness of 
the limbs. At the end of a month the feebleness was such that she 
could not leave her bed. About the same time the trembling ceased, 
but was succeeded by a contraction which affected at first the extremi- 
ties of the left side, but in the course of three weeks involved those of 
the right side also. The neck also became rigid. 

All these phenomena persisted, they even increased so that in the 
early part of 1850 she was admitted into the Charite. 

At that time she was confined to her bed in the dorsal decubitus, 
not being able to move her limbs. Her general health was good, and 
her cerebral functions were normal. The muscles of the neck were 
painful and stiff. The skin on the left anterior part of the thorax was 
hyperaesthetic, the condition being exactly bounded by the median line. 
The tactile sensibility was a little obtuse in the left superior extremity, 
but the sensibility to pain was exaggerated. The muscular sensibility 
was also more marked than in the normal state. 

The superior extremities were strongly contracted; the forearm was 
flexed on the arm, and the fingers were also strongly flexed. Attempts 
made to extend the limbs were only partially successful and caused 
pain. The contracted muscles were the seat of continuous spontaneous 
pains, and from time to time sudden movements took place in these 
members, either spontaneously or as a consequence of reflex action. 
Neither of these limbs could be moved by voluntary power. 

The trunk was rigid and its muscles were painful to pressure. 
Pressure on the cervical region of the skin also caused pain. 

Both inferior extremities were also strongly flexed. Pressure on 
the muscles caused pain, and there were also darting pains through these 
limbs. 

The case was regarded as one of hysteria. The patient remained in 
the hospital two years, and left in about the same state as when she 
entered. Subsequently the symptoms almost entirely disappeared, 
nothing remaining but a weakness of the lower extremities and a slight 
degree of contraction of the upper. But in 1855 she had another hys- 
terical attack, and this was followed by a return of the former con- 
dition. 

In 1856 she entered the Salpetriere, and in 1862 her case was 
studied by M. Charcot. The symptoms were similar to those which 

1 Cited by Bourneville, ''De la contraction hysterique permanente," Paris, 1872, p. 77. 



552 DISEASES OF THE SPINAL CORD. 

have been described, though even more pronounced. In 1864 she died 
during an attack of erysipelas. 

The post-mortem examination showed the essential lesion to consist 
of sclerosis of the lateral column from the medulla oblongata to the 
lower boundary of the lumbar enlargement. The gray matter was 
healthy throughout. 

A study of this case shows that the principal symptoms of primary 
symmetrical lateral sclerosis are as Ttirck described them in his mem- 
oir — paralysis, contractions, and pain in the back and limbs. To these 
must also be added the exaggerated knee-jerk and the ankle clonus. 

Causes. — The causes of the disease are probably similar to those 
producing so many other spinal affections — cold, dampness, over-exer- 
tion, syphilis. Nothing very definite is known on the subject. 

Diagnosis. — The elements of the diagnosis of primary symmetrical 
lateral sclerosis of the spinal cord are the presence of contractions with 
paralysis but without atrophy, and the absence of any organic disease 
of the brain or superior part of the cord (bulb) which could give rise to 
the condition as a secondary disorder. It must, however, be borne in 
mind that contractions are the expression of degeneration of the lateral 
pyramidal tract. It is only by attention to the clinical history of the 
case that we can ascertain whether the lesion is primary or secondary. 
But it must be remembered that it is a matter of the most rare occur- 
rence for the motor tracts of both hemispheres to undergo degenera- 
tion simultaneously, while in the spinal cord it is equally rare to find 
the disease limited to one lateral pyramidal tract only. 

The distinction between the disease in question and progressive 
muscular atrophy is so clear as scarcely to require comment, and from 
amyotrophic lateral spinal sclerosis, the absence of atrophy and its ac- 
companiments, and of a tendency to attack the nuclei of the bulbar 
nerves, will serve to make the discrimination. 

It has more affinities, so far as its symptoms are concerned, with 
chronic spinal meningitis, multiple spinal sclerosis, and with tumors 
which, by their pressure on the cord, may give rise to very similar 
phenomena to those exhibited in lateral sclerosis. I am afraid the 
difficulties of making a diagnosis between it and these affections are, 
in the present state of our knowledge, almost insurmountable. I know 
of no sure signs by which the discrimination can be made. 

Prognosis. — Although remissions may take place, the prospect of 
an entire cure is not very great. The progress of the disease is, how- 
ever, slow in the majority of cases, and its course may, I am satisfied, 
be materially retarded if not altogether arrested in some cases. 

Morbid Anatomy and Pathology. — Turck was the first to associate 
sclerosis of the lateral columns with a definite set of symptoms. In 
three of the cases of the twelve on which his memoir is based he found 
these regions of the cord the seat of symmetrical sclerosis. It has been 



INFLAMMATION OF THE LATERAL COLUMNS. 



553 



very definitely settled that the lateral columns are, in embryonic life, 
anatomically distinct from the rest of the cord ; and, though in the 
process of development this anatomical separation is apparently lost, 
pathology shows us that it in reality exists. 

Charcot, 1 in considering this subject, calls attention to the fact 
that transverse sections of the cord in cases of primary symmetrical 



Fig 



Fig. 67. 



Fig. 




Fig 



lateral sclerosis made through the cervical enlargement show that the 
alteration embraces a greater extent of the cord than when any other 
part is affected. Thus, when the region in question is the seat of the 
lesion, the sclerosis extends anteriorly as far as, and even beyond, the 
external angle of the anterior horn, while posteriorly it almost en- 
croaches on the posterior tract of gray matter. On the outside it is 
always separated from the cortical layer by a tract of white tissue 
which remains intact. 

In Fig. 66 is represented a transverse section of the cord made 
through the cervical enlargement, a denotes the sclerosed portion ex- 
tending beyond- the external angle of the anterior tract of gray matter 
reaching to the posterior tract behind, and separated from the cortex 
by a layer of unaltered white substance. 

In the dorsal region the lesion is more 
circumscribed, as is seen from an examina- 
tion of Fig. 67, which represents a section 
of the cord through the middle of that 
part. In front it scarcely reaches the 
posterior boundary of the anterior tract 
of gray matter. As in the section just 
described, the sclerosed portion does not 
extend to the cortical layer of the cord. 

In the lumbar region the lesion is still 
less extensive, occupying only about a quarter of the area of the lat- 
eral columns. Unlike the lesion in the cervical and dorsal regions, it 
touches the cortical layer of the cord (Fig. 68). The undegenerated 
white matter situated on the periphery of the lateral pyramidal tracts 
from the lower dorsal region upward is the direct cerebellar tract. 
This tract is not found in the lumbar region. 

Finally, in those cases in which the morbid process extends to 
the medulla oblongata, we find it seated in the anterior pyramids, 

1 Op. cit, p. 220. 




554 



DISEASES OF THE SPINAL CORD. 



not in the nuclei of the bulbar nerves, as in cases of amyotrophic lat- 
eral spinal sclerosis to be presently considered. Fig. 69 represents 
a transverse section of the medulla oblongata through the middle 
part of the olivary bodies ; A A, the anterior pyramids in a state of 
sclerosis. 

In primary symmetrical lateral sclerosis the initial stage, as in 
other inflammatory affections of the spinal cord, whether acute or 
chronic, is probably congestion. This congestion begins in the axis 
cylinders of the nerve tubes and eventually becomes a chronic inflam- 
mation. From the axis cylinder the inflammation extends to the 
nerve and sheath and eventually to the connective tissue, which 
undergoes proliferation and, by its increase in volume, presses upon and 
gradually destroys the nerve tubes. This evidently accounts for the 
paresis which is the initial symptom of the disease. As the nerve 
fibres descend they are continually branching off to connect with the 
motor cells in the anterior horn of gray matter. This accounts for 
the gradual diminution in the area of the lateral pyramidal tracts as 

Fig. 70. 




pMC. 



Diagrammatic representation of the connection between the lateral pyramidal tract and the 
motor cells in the anterior horn; also the reflex fibres. (Modified from Bramwell.) 

pmc, Posterior median column, or column of Goll. pec, Posterior external column, or 
column of Burdach, through which a deep reflex fibre (J?) passes to join the motor 
cell at 3. S, A superficial reflex fibre passing through the posterior horn of gray 
matter to join the motor cell at 2. lp t, Lateral pyramidal tract, from which a motor 
nerve-fibre (1) passes to the motor cell. 4, Motor fibre to a muscle. 5, Fibre to 
neighboring cells. 6, Fibre to motor cells in opposite horn. 



they descend. The inflammatory process is transmitted by these 
fibres to the motor cells in the anterior horn which are thereby kept 
in a state of continual irritation. 



INFLAMMATION OF THE LATERAL COLUMNS. 555 

All motor cells by constant vibration keep the muscles which they 
supply moderately contracted, or, as it is commonly termed, " in tone." 
This is beautifully demonstrated in Bell's facial paralysis, where one 
side of the face is paralyzed. The normal " tone " of the paralyzed 
side having been abolished, the face is drawn toward the sound side. 

When the motor cells are in a constant state of irritation, the nor- 
mal " tone " of the muscles which they supply is enormously increased. 
Hence the stiffness and rigidity of the limbs. The exaggerated knee- 
jerk and the ankle clonus are, in my opinion, both due to the irritable 
condition of the motor nerve-cells. It is claimed by most authors that 
these two symptoms are caused by the abolition of the power of 
transmitting inhibitory impulses through the lateral pyramidal tracts 
owing to their diseased condition. It is claimed that when a healthy 
individual is struck on the patellar tendon that he can restrain the 
knee-jerk if he desires to, and that, in any case, there is a certain 
amount of involuntary restraint ; and that in disease of the lateral 
pyramidal tract this power of inhibition is lost. This theory is not, 
to my mind, supported by evidence. A healthy individual controls 
the manifestation of the tendon reflex by contracting the flexors of 
the leg, but not by any mental influence directed against the knee- 
jerk impulse. As for involuntary inhibition, if there is such a thing, 
its loss should be manifested immediately after a cerebral haemorrhage, 
which, as Althaus 1 points out, is not the case. The exaggerated knee- 
jerk and the ankle clonus do not appear until the descending degener- 
ation has reached the lateral pyramidal tract. 

On the other hand, it is not difficult to believe that irritable nerve- 
cells will send out irritable impulses under stimulation. Hence, if a 
blow is struck on the patellar tendon of an individual suffering from 
sclerosis of the lateral columns of the cord, and in whom the motor 
cells in the anterior horn must necessarily be in a constant state 
of irritation, and the sensory impulse from the blow reaches these 
cells, an irritable motor impulse will result and an exaggerated knee- 
jerk will necessarily follow. (See Fig. TO.) 

The ankle clonus is the exaggerated reflex of the gastrocnemius. 

Treatment. — In the early period of the disease large doses of ergot 
will rarely fail to be of service. I have several times succeeded in 
relieving the paralysis and arresting the spasms of the limbs in cases 
presenting all the initial phenomena of lateral sclerosis by the persistent 
and free use of this remedy. But to be efficacious it must be given in 
the very first stage, before the paralysis becomes extreme, or perma- 
nent contractions are present. A drachm of the fluid extract three 
times a day is the smallest dose likely to prove efficacious. 

If there is reason to suspect the influence of syphilis in producing 
the disease, the iodide of potassium in large and gradually-increasing 

1 " Sclerosis of the Spinal Cord." 



556 DISEASES OF THE SPINAL CORD. 

closes should be administered. Charcot and Gombault ' have proved 
the existence of disseminated sclerosis of the cord in a woman affected 
with syphilis, and there is of course reason to believe that the diffused 
form such as that now under consideration may have a like origin. 

In such cases mercury may also be given, preferably in the form 
of the bichloride, with the iodide of potassium. 

Later, no treatment is, so far as we know, calculated to materially 
arrest the progress of the disease. Nitrate of silver and cod-liver oil 
have also occasionally improved the strength of the patient and less- 
ened the rigidity of the contractions, but only for a short time ; and 
the primary uninterrupted galvanic current to the spinal column and 
the contracted muscles has also proved serviceable in the same way 
and to a like extent. 

Up to quite a recent period I had never derived any benefit in 
cases of lateral sclerosis from counter-irritation, but I am disposed to 
think from some late experience that the actual cautery, applied on 
each side of the spinous processes throughout the entire length of the 
vertebral column and frequently repeated, is useful. 

For the relief of pain, morphia may be administered, or what is, I 
think, preferable, as it does not appear to be an excitant of the cord, 
codeine. Half a grain or more may be given as required. 

Hypodermic injections of atropia, beginning with the one hundred 
and twentieth of a grain and increasing gradually, are beneficial in 
mitigating the spasms of the muscles. 

VI. 

INFLAMMATION OF THE LATERAL COLUMNS OF THE SPINAL CORD AND 
OF THE ANTERIOR TRACT OF GRAY MATTER (AMYOTROPHIC LAT- 
ERAL SPINAL SCLEROSIS. 

For the recognition of this affection and the patho-anatomical data 
relative to its identity, we are indebted to Charcot, who, with his cus- 
tomary ability, has presented a mass of facts abundantly sustaining 
his views in regard to its autonomy. Cases exhibiting the phenomena 
of amyotrophic lateral spinal sclerosis were noticed, and their details 
published before he enunciated his doctrines on the subject ; but the 
relations of the lesions to the symptoms were not known previous to 
his observations. 

Symptoms. — The first symptom to make its appearance in the 
affection under notice is paralysis, which occurs ordinarily gradually, 
advances steadily, and may involve at the same time one or more of 
the limbs. Generally atrophy ensues soon after the appearance of the 

1 " Note sur une cas des lesions disseminees des centres nerveux observees chez une 
femme syphilitique," Archives de physiologie, 1873, p. 143. 



AMYOTROPHIC LATERAL SPINAL SCLEROSIS. 557 

paralysis, and, as in infantile spinal paralysis, and the spinal paralysis 
of adults, involves whole groups of muscles at once — not the individ- 
ual muscles in succession, as in progressive muscular atrophy. 

After a time the morbid process in its ascending course reaches 
the medulla oblongata, and, thus implicating the nuclei of the facial, 
spinal accessory, hypoglossal, and pneumogastric nerves, especially the 
two latter, causes atrophy of the tongue, and many of the other 
symptoms met with in progressive muscular atrophy affecting these 
centres. Finally, death takes place from interruption to the processes 
of respiration and circulation. 

The muscles which are the seat of atrophy are subject, as in pro- 
gressive muscular atrophy, to fibrillary contractions, which, however, 
as in the last-named affection, precede the atrophy, and advance and 
attain their greatest development pari passu with the wasting. 

The electrical reactions of the affected muscles show both qualita- 
tive and quantitative degenerations. As the atrophy progresses the 
muscles respond less and less to the faradaic current, and finally cease 
to respond to it at all. At first there is a gradual decline of the gal- 
vanic contraction, but at the expiration of a few weeks' time it will 
be observed that moderately strong currents produce good contrac- 
tions ; but it will also be noticed that the anodal closure contraction 
equals or excels the cathodal closure contraction. In other words, the 
polar reactions of degeneration (see page 28) are present. 

But the feature which is most characteristic of amyotrophic lateral 
spinal sclerosis is the permanent contractions of which the affected 
limbs are the seat. These, though in part due, as Charcot ' says, to the 
paralysis of certain antagonistic muscles, are mainly caused by spas- 
modic contractions of the non-paralyzed or partially paralyzed muscles, 
so that the joints are rigidly flexed. The position assumed when the 
forearm and hand are the seat of this deformation, is shown in Fig. 71. 
The fingers are flexed upon the palm, the thumb adducted, and the hand 
strongly bent upon the arm. 

In the case of a gentleman who came under my observation in Sep- 
tember, 1874, the position of the left hand was very similar to that 
shown in the figure. The arm was semiflexed, and the whole member 
held firmly against the walls of the chest, by the action of the pectoral 
and latissimus dorsi muscles. Any attempt to overcome the contrac- 
tions was strongly resisted by the muscles, and caused very consider- 
able pain. The atrophy of the paralyzed muscles was well marked, 
and fibrillary contractions were easily excited, even if not present 
when the inspection was made. 

In this case the disease had appeared suddenly six months previous- 
ly, after exposure subsequent to a debauch. The upper extremities 

lu Le9ons sur les maladies du systeme nerveux," 3me fascicule, Paris, 1874, 
p. 234. 



558 



DISEASES OF THE SPINAL CORD. 



only were affected, but there was, even when I saw the patient, a little 
restraint in the movements of the tongue. I did not see him again, 
but I heard that death had ensued from dysentery three months after 



Fig 




his visit to me. I also learned that his tongue had become atrophied, 
and that there was difficulty of swallowing. 

In another case the contracted muscles were the pectorals, and the 
left arm was, in consequence, drawn strongly across the front of the 
chest. This patient, a man forty years of age, was paralyzed in both 
upper extremities, but the contraction, when I first saw him, was limited, 
as stated, to the pectoral muscles. He visited me again about six months 
afterward, and then the right upper extremity was also contracted 
throughout its extent. The fingers were bent on the palm to such a 
degree that they could not be opened by any force which it was safe 
to apply, and pressed so strongly on the palm as to cause pain. If the 
nails were allowed to project beyond the ends of the fingers — and it 
was very difficult to keep them short — they entered into the skin and 
caused painful sores. The hand was flexed on the wrist, the elbow half 
bent, and the arm was held firmly against the side* of the chest. At 
the time of the first visit of this patient there was no evidence of any 
alteration of the medulla oblongata, but at the second visit there were 
several indications of incipient bulbar paralysis. Deglutition was effect- 
ed with difficulty, the tongue could not be carried to the roof of the 
mouth, was protruded only slightly upon great effort being made, and 
was the seat of constant fibrillary contractions. 

The atrophy of the paralyzed muscles was well marked, and fibril- 
lations were so strong as to be a source of great discomfort. The 
lower extremities were not then involved, and the bladder and sphinc- 
ters were intact. I have not seen the patient since — now about seven 
months — and am ignorant of the subsequent course of the disease. 



AMYOTROPHIC LATERAL SPINAL SCLEROSIS. 559 

The contractions are not always similar, either in extent or strength, 
in the corresponding limbs, and they may for a time, especially in the 
early stages of the disease, disappear. But they reappear later, and 
tend to become more and more rigid as the affection advances ; still, 
in the most extreme period of the malady, as the atrophy becomes pro- 
nounced, they disappear wholly or in part, there being little if any 
muscle left to maintain the contraction. 

Another feature is a spasmodic extension of the paralyzed limbs, 
especially the lower, which is most strongly marked as the patient lies 
in bed ; or the members may be involuntarily flexed and remain in that 
condition for several minutes or longer. These movements are not ordi- 
narily accompanied with pain, as are those of spinal meningitis, which 
in many respects they resemble. 

The patient very generally experiences severe pains in the affected 
limbs, which are aggravated or excited by pressure or traction in the 
muscles. Numbness is also usually present to a greater or less degree, 
but there is never complete anaesthesia. 

A peculiar kind of tremor is sometimes seen in the limbs, the mus- 
cles of which are partially paralyzed and atrophied. This is in reality 
not so much a tremor as it is a more extensive movement, resembling 
that which is present in some old cases of hemiplegia from cerebral 
haemorrhage. It is only, like that, manifested when voluntary move- 
ments are attempted. 

As previously stated, the disease, unless death ensues from some in- 
tercurrent affection, eventually extends to the medulla oblongata. In 
none of my cases has this circumstance been present to any marked 
degree while the patients were und,er my observation ; but in two, as 
we have seen, there were indications of such extension when they 
passed from under my notice. Charcot states it to be an invariable se- 
quence, so far as his observations extend, and he sums up the subject 
as follows : The paralysis of the tongue, inducing a difficulty of swal- 
lowing and of articulation, may cause a complete loss of the power of 
speech. The paralyzed tongue presents very soon, in general, a cer- 
tain degree of atrophy ; it is shrunken, wrinkled, and agitated with 
vermicular movements. ' 

The paralysis of the veil of the palate makes the voice nasal, and, 
with the laryngeal paralysis, renders the act of deglutition difficult. 

The orbicularis oris being paralyzed, an alteration in the form of 
the countenance takes place. The mouth is considerably enlarged 
transversely, through the predominance of the action of the muscles 
which are not involved. The naso-labial furrows are depressed. The 
symptoms give to the physiognomy a sad expression. The mouth, es- 
pecially after laughing or weeping, remains for a long time half open, 
and allows the viscid saliva to flow continually. 

Finally, by reason of the implication of the pneumogastrics, grave 



560 DISEASES OF THE SPINAL CORD. 

troubles of the respiration and circulation supervene, and cause the 
death of the patient, already weakened by insufficient nourishment* 

In some cases there are variations from the ordinary course of the 
disease. It has begun in the lower extremities instead of the upper, 
and again has been restricted in its domain for a long time to a single 
limb or to one side of the body. In two cases, according to Charcot, 
it has begun with the bulbar symptoms, which in general appear only 
at the end. In regard to such instances as these last, there is doubt of 
their being examples of amyotrophic lateral sclerosis. 

Causes. — Exposure to cold and dampness appears to be the most 
efficient exciting cause of the disease. In one of Charcot's 1 cases, the 
patient, an itinerant showman, was exposed during a journey to cold 
and rain. The following morning he was taken with a chill, which was 
repeated thirty-six hours afterward, and then he was seized with pains 
along the course of the nerves, and in the joints mainly of the upper 
extremities. Fibrillations accompanied them, and paralysis and atrophy 
soon followed. In the case occurring in my own experience, the patient 
became intoxicated, and wandering into the Central Park, lay all night 
on wet grass, exposed to a cold, drizzling rain. In the morning he was 
arrested and taken to the police court, and sent to Blackwell's Island for 
ten days. On his way up, he was subjected to the influence of a cold wind, 
which, blowing on his wet clothes, chilled him more and more. The 
following morning he was discharged, his friends having ascertained 
his situation and paid his fine. But he already felt a degree of weak- 
ness in his arms, and in the course of a week they were to a great 
extent deprived of motor power. Fibrillary contractions were present 
from the first, but there was no pain anywhere. 

In the majority of cases no cause can reasonably be assigned. There 
appears to be no hereditary influence to the disease. 

Diagnosis. — The diagnosis of amyotrophic lateral spinal sclerosis 
presents many features of interest. A consideration of the essential 
phenomena shows that they are as follows : 

1. Paralysis occurring in symmetrical parts of the body, unaccom- 
panied by anaesthesia. 

2. Atrophy following the paralysis, and attacking masses of mus- 
cles. 

3. Spasmodic rigidity, eventually leading to permanent contrac- 
tions, lasting up to the last stage of the disease. 

4. Extension of the affection to the lower extremities, and the su- 
pervention of intermittent and tonic contractions or rigidity. 

5. The implication of the medulla oblongata, and death in the 
course of two or three years. 

Thus, we see that the affinities of amyotrophic lateral spinal sclero- 
sis are with spinal paralysis of adults and progressive musoular atrophy, 
1 " Deux cas d'atrophie musculaire progressive," Archives de physiologie, 1869, p. 687. 



AMYOTROPHIC LATERAL SPINAL SCLEROSIS. 561 

with which latter disease it was confounded by Dumesnil, 1 Charcot, 3 
and others, up to quite a late period. 

But the differences between it and both these diseases are suffi- 
ciently striking to prevent much danger of confounding them. Thus 
from spinal paralysis of adults it is discriminated by the facts that 
reflex excitability is not impaired, nor the electric excitability of the 
muscle diminished, as in the former affection ; that the atrophy is more 
profound and constant; that fibrillations are present, and especially by 
the existence of t.he spasmodic contractions of the limbs which form so 
prominent a feature of amyotrophic lateral spinal sclerosis. 

From progressive muscular atrophy the distinction can be readily 
made out. In the facts that paralysis precedes the atrophy, that the 
wasting takes place in groups of muscles, and that spasmodic contrac- 
tions occur in amyotrophic lateral spinal sclerosis ; while in progres- 
sive muscular atrophy the paralysis is consequent on the wasting, the 
muscles shrink singly and irregularly, fibre by fibre, and spasmodic con- 
tractions do not occur, we have sufficiently precise diagnostic marks of 
differences between the two affections. 

Prognosis. — There is no case of cure on record. The course of the 
disease is progressively onward. In the majority of cases the fatal ter- 
mination occurs within two years ; occasionally, it is deferred for a few 
months longer. 

Morbid Anatomy and Pathology. — As I have said, amyotrophic 

lateral spinal sclerosis has, until quite lately, been regarded as, at most, 
an 'eccentric form of progressive muscular atrophy. It is among the 
reports of cases of this affection, therefore, that we must search for 
early data relative to the morbid anatomy of the disease under consid- 
eration. 

Dumesnil, 8 in 1867, reported the details of five cases of spinal disease 
under the name of progressive muscular atrophy, two of which were, 
undoubtedly, instances of amyotrophic lateral spinal sclerosis. In both 
of these, symptoms such as have been described were present, and, on 
post-mortem examination, lesions of the lateral columns and anterior 
horns of gray matter were found to exist. 

Charcot and Joffroy 4 have given with fullness of detail the particu- 
lars of two cases of amyotrophic lateral spinal paralysis, in which the 
post-mortem examination was very thorough. 

1 " Nouveaux faits relatifs a la pathogenie de l'atrophie musculaire progressive,'' 
Gazette hebdomadaire, Nos. 27, 29, 30, 1867. 

2 " Deux cas d'atrophie musculaire progressive avec lesions de la substance grise et 
des faiseaux antero-lateraux de la moelle epiniere," Archives de physiologie, No. 4, 1869. 

3 "Nouveaux faits relatifs a la pathogenie de Tatrophie musculaire progressive,* 1 
Gazette hebdomadaire, Nos. 27, 29, 30, 1867. 

4 " Deux cas d'atrophie musculaire progressive avec lesions de la substance grise et 
des faiseaux antero-lateraux de la moelle epiniere," Archives de physiologie, 1867. 

37 



562 DISEASES OF THE SPINAL CORD. 

The first of these is reported as a case of progressive muscular 
atrophy, especially marked in the upper extremities, with atrophy of 
the muscles of the tongue and of the orbicularis oris and paralysis with 
rigidity of the inferior limbs. On post-mortem examination the nerve- 
cells of the anterior horns in the cervical and dorsal regions were found 
atrophied, while many had disappeared. In the bulb there were atrophy 
and disappearance of the nerve-cells, constituting the nucleus of the 
hypoglossal. The anterior roots of the spinal nerves and the roots of 
the hypoglossal and the facial were also atrophied. In addition, there 
was symmetrical diffused sclerosis of the lateral columns. In this case 
the bulb was affected after the lower parts of the cord, and the lesion 
of the nuclei of the hypoglossal and facial was of such a nature as to 
cause atrophy of the tongue and orbicularis-oris muscle. The instance 
was, therefore, of a typical character. 

The second case has already been cited under another head of this 
chapter. It is entitled — Progressive muscular atrophy especially mani- 
fested in the upper extremities; acute pains in the limbs coming on in 
paroxysms ; anaesthesia in certain parts of the body ; paralysis with 
rigidity of the inferior extremities; lesions of the nerve-cells of the 
anterior horns of gray matter; centres of gray degeneration in the 
posterior horns; symmetrical diffused sclerosis of the lateral columns ; 
considerable thickening of the spinal dura mater and pia mater of the 
cervical enlargement. 

This case was not an uncomplicated one, but still the essential 
lesions of the anterior horns of gray matter and of the lateral columns 
are perceived to have been present. 

Gombault 1 reports the case of a woman in whom the symptoms 
were not developed with any suddenness, but in whom there gradually 
supervened loss of power with atrophy and contractions in the upper 
extremities, then paralysis with atrophy in the lower limbs, and finally 
atrophy of the muscles of the tongue and lips, with difficulty of swal- 
lowing, and the other symptoms of glosso-labio-laryngeal paralysis. 
Post-mortem examination showed the lateral columns to be symmetri 
cally sclerosed, and in the anterior horns of gray matter symmetrical 
lesions, exactly limited to this region, and consisting of atrophy, pig- 
mentary degeneration, and disappearance of the nerve-cells. In the 
bulb, the nuclei of origin of the bulbar nerves were similarly altered. 

It is perceived, therefore, that in amyotrophic lateral spinal sclero- 
sis the essential lesions are seated symmetrically in the lateral columns 
and in the anterior horns of gray matter, and that when the morbid 
process extends — as it always does, if the patient does not die in the 
mean time of some intercurrent affection — to the medulla oblongata, it 

1 " Sclerose symetrique des cordons lateraux de la moelle et des pyramides anterieurs 
dans la bulbe ; atropine des cellules des cornes anterieures de la moelle ; atrophie mus« 
culaire progressive; paralysie glosso-laryngee," Archives de physiologie, 1872, p. 589. 



AMYOTROPHIC LATERAL SPINAL SCLEROSIS. 



563 



invades the nuclei of origin of the nerves which are affected in glosso- 
labio-laryngeal paralysis. The accompanying woodcut from Charcot 




represents a section of the bulb made at the level of the middle part 
of the nucleus of the hypoglossal ; a b to the right of the imaginary 
line R R' represents the normal condition ; <7, the nucleus of the hypo- 
glossal composed of about thirty multipolar ganglion-cells; e, a vessel 
circumscribing the nucleus; e, the floor of the fourth ventricle; d, the 
fasciculus teres ; b, nucleus of the pneumogastric. On the left the 
letters a' b\ etc., represent the corresponding parts in a case of amyo- 
trophic lateral spinal sclerosis. It is perceived that only five or six 
cells exist in the nucleus of the hypoglossal. The nucleus of the pneu- 
mogastric is, on the contrary, normal. 

Now, it appears to me that M. Charcot is wrong in considering, as 
he apparently does, every case of glosso-labio-laryngeal paralysis ac- 
companied by progressive muscular atrophy of the muscles lower 
down, as one of primary amyotrophic lateral spinal sclerosis. 

Those cases of glosso-labio-laryngeal paralysis which, at a later 
period, exhibit the phenomena of progressive muscular atrophy in the 
muscles of the upper extremities and of other parts of the body are, in 
my opinion, not cases in which there is primitive lesion of the lateral 
columns, but examples of secondary degeneration of the cord, being 
produced as a consequence of the superior lesion. 

The case reported by Dr. Hun, 1 of Albany, is quoted by Charcot a as 
an instance of amyotrophic lateral spinal sclerosis, but, according to the 

1 " Labio-Glosso-Laryngeal Paralysis," American Journal of Insanity, 1871, p. 194. 

2 "Le9ons sur les maladies du systeme nerveux," Paris, 18*74, p. 229- 



564 DISEASES OF THE SPINAL CORD. 

view above expressed, it was in reality a case of glosso-labio-laryngeal 
paralysis with secondary degeneration of the spinal cord. The patient, 
a man aged fifty* eight, first noticed that the saliva dribbled from his 
mouth when speaking or writing. Shortly afterward he was conscious 
of a difficulty in the pronunciation of words, and then there were evi- 
dent hesitation and defect in the articulation of certain words, and his 
voice became nasal. 

A year afterward there were complete loss of speech, difficulty of 
deglutition — any effort at swallowing being attended with paroxysms of 
coughing and suffocation — and paralysis of the tongue, which could only 
be protruded a quarter of an inch beyond the edge of the teeth. There 
was partial loss of motion in both arms, but no atrophy. 

A month subsequently it was noticed that he dragged his feet a 
little, but he could still walk alone for a considerable distance. The pa- 
ralysis advanced until he was unable to walk, and the difficulty of deglu- 
tition increased. 

"When seen by Dr. Hun, January 4, 1871, " he was sitting in a 
chair propped up by pillows, being unable to lie down on account of 
dyspnoea; complete loss of motion except a little nodding of the head 
and a little movement of the right hand; sight and hearing unimpaired; 
speech entirely lost; mouth partly open; and lips immovable, except a 
slight twitching of the left angle of the mouth; cheeks flaccid; tongue 
completely paralyzed and lying on the floor of the mouth; respiration 
feeble, and occasional coughing ; pulse 90 per minute and regular ; 
both arms paralyzed and slightly flexed, and attempts to straighten the 
fingers caused pain; lower extremities completely paralyzed, and feet 
and ankles cedematous ; defecation natural ; micturition slow and fre- 
quent; attempts to swallow occasioned distressing cough and suffoca- 
tion, and the aliments were often rejected through the nose. 

" He remained in this condition until the afternoon of the same day, 
when an attempt to swallow some porridge brought on severe coughing 
and strangling. At seven o'clock that evening he died without a strug- 
gle. 

" Autopsy twenty hours after death. 

" External Appearances. — Rigor mortis well marked. Body spare 
but not emaciated, no very evident signs of muscular atrophy. 

" Head. — Scalp very dry. Skull-cap removed with great difficulty, 
owing to adhesions of the dura mater, which was torn in trying to sepa- 
rate it from the bone. Dura mater very much thickened. Arachnoid 
normal with considerable serous infiltration of the sub-arachnoidean 
connective tissue. Pia mater much injected. The cerebral substance, 
both cortical and medullary, appeared to be of normal color and consist- 
ency but exceedingly hyperaemic. The following conditions of the 
cranial nerves were found : 1. Olfactory normal; 2. Optic normal; 3. 
Motor oculi normal ; 4. Patheticus small ; 5. Trigeminus, on the left 



AMYOTROPHIC LATERAL SPINAL SCLEROSIS. 565 

side flattened, gray, and softened; on the right side larger and very hy- 
peraemic; 6. Abducens atrophied especially on the left side; 7. Facial 
atrophied and gray on both sides ; 8. Auditory normal ; 9. Glossopha- 
ryngeal normal; 10. Pneumogastric atrophied on both sides; 11. Spinal 
accessory much atrophied ; 12. Hypoglossal so much atrophied on 
both sides as to resemble mere threads or filaments of connective tissue. 
The corpora striata and optic thalami were normal. The cerebellum 
was very hyperaemic, but otherwise presented nothing unusual. The 
pons Varolii and medulla oblongata appeared to be of firmer consistency 
than usual. 

" Spinal Cord. — Spinal meninges much injected. The anterior 
spinal roots were atrophied, especially on the left side. Transverse sec- 
tions of the cord showed the anterior cornua of gray matter, as well as 
the left anterior and right lateral column, to be of a dark rose-color, as if 
very hyperaemic. 

" Portions of the brain, cerebellum, and spinal cord were immersed in 
absolute alcohol, preparatory to making sections for microscopic exami- 
nation. When sufficiently hardened, thin sections were made, stained 
with carmine, rendered transparent with benzole, and mounted in bal- 
sam. 

" The sections of the brain revealed nothing abnormal. The sec- 
tions of the cerebellum showed a very hyperaemic condition of the part, 
and a granular degeneration of the large ganglionic cells forming the 
middle layer of the cortical portion. 

" Thirty sections were made at various levels of the medulla oblon- 
gata, involving the roots and nuclei of implantation of the cranial 
nerves, especially those of the facial and hypoglossal. Careful micro- 
scopic examination of these specimens, with objectives varying from 
fifteen to nine hundred diameters, demonstrated that the portion of 
medulla forming the floor of the fourth ventricle was the seat of several 
pathological lesions. 

" There was a decided hypertrophy or overgrowth of the connective 
tissue, which appeared to have encroached upon and to some extent 
replaced the several groups of ganglionic cells which form the nuclei of 
implantation for the facial and hypoglossal nerves. The individual 
cells comprising these groups were separated from one another, and in 
many instances had lost their stellate appearance ; their radiating pro- 
cesses having been destroyed, so that each cell remained isolated and 
disconnected from its neighbors. These cells had also undergone a de- 
generative process, which in many cases rendered them simply a collec- 
tion of fine granules, and a deposit of brownish-yellow pigment had 
taken place to such an extent as to give the cells an appearance almost 
precisely similar to those which are normally found in the locus niger 
of Soemmering ; they were fewer in number than usual and diminutive 
in size. 



566 DISEASES OF THE SPINAL CORD. 

" Sections of the cord made in the cervical, dorsal, and lumbar re- 
gions, showed a sclerosis with increase of the connective tissue in the 
anterior and lateral columns, which was most marked in the left ante- 
rior and lateral columns. The multipolar ganglion cells, situated in the 
anterior cornua of gray matter, were fewer in number than usual, and 
many of them appeared granular and very much pigmented." 

As Dr. Hun subsequently remarks, there was here " a descending 
degeneration of the motor tracts of the cord consecutive to a primary 
lesion situated in the medulla. This is fully in accordance with the 
views presented by Bouchard in his work on secondary degenerations 
of the spinal cord, and accounts for the progressive paralysis of the 
trunk and extremities which follows the original loss of motion in the 
lips, tongue, and palate." 

The cases cited by M. Charcot from Leyden ' are similar in general 
characteristics. 

To repeat, glosso-labio-laryngeal paralysis is a paralysis without 
atrophy. Paralysis and atrophy consequent to it of other parts lower 
down, are due to secondary degenerations of the cord. Amyotrophic 
lateral spinal sclerosis is a paralysis with atrophy. It has a tendency 
to ascend and to involve the nuclei of the bulbar nerves, causing the 
atrophy of the muscles of the lips, tongue, and palate, and accompanied 
with fibrillary contractions, which latter are not phenomena of glosso- 
labio-laryngeal paralysis. 

Such cases as those of Hun, Leyden, and others, as well as several 
which have come under my own experience, are, so far as their lower 
spinal phenomena are concerned, to be classed not with the protopathic, 
but the deuteropathic spinal amyotrophies of Charcot, the secondary 
spinal degenerations of Bouchard, to which attention will be given 
hereafter. 

Even if we adopt M. Charcot's view that in such cases there is a 
real atrophy of the tongue, which is concealed by the hyperplasia of 
the perimysium, and the deposit of fat between the muscular fibres, we 
could not avoid perceiving the difference between such instances and 
those of true progressive muscular atrophy attacking the tongue, and 
in which there are fibrillations, and no interstitial fat to mask the ver- 
itable condition. 

The lesions of the muscles in amyotrophic lateral spinal sclerosis are 
similar to those met with in progressive muscular atrophy. The peri- 
mysium is increased in quantity and the muscular fibrillae undergo fatty 
degeneration and atrophy. 

In considering the relation of the phenomena to the lesion, the ques- 
tions to engage attention are mainly those which have already been suffi- 
ciently dwelt upon, when the other affections characterized by paralysis 
and atrophy were under notice. One symptom, spasmodic contraction, 

1 "Ueber progressive bulbare Paralysie," Archiv fur Psychiatrie, Band ii., S. Hi. 



PROGRESSIVE LOCOMOTOR ATAXIA. 567 

a concomitant of primary symmetrical spinal sclerosis, is, as has been 
pointed out when that disease was under consideration, the direct con- 
sequence of the lesion of the lateral columns. 

Treatment. — In regard to a malady of so hopeless a character as 
amyotrophic lateral spinal sclerosis, there is little or nothing to say 
under this head. We have no means at our command capable of 
arresting the onward tendency of the disease. 

VII. 

INFLAMMATION (SCLEROSIS) OF THE POSTERIOR ROOT-ZONES OF THE 
SPINAL CORD (PROGRESSIVE LOCOMOTOR ATAXIA), (TABES DORSALIS). 

In the former editions of this work I described locomotor ataxia 
under the designation — based upon its patho-anatomy as then under- 
stood — of posterior spinal sclerosis. The recent investigations of 
Charcot and his pupils have, however, shown that the morbid process 
which gives rise to the remarkable group of symptoms known as loco- 
motor ataxia is in reality situated in the subdivisions of the posterior 
columns, lying between the columns of Goll and the posterior horns 
of gray matter, and called the posterior root-zones. In accordance, 
therefore, with its exact morbid anatomy, tabes dorsalis should be 
designated by the term placed at the head of this section. But, for 
convenience, I shall generally use the name locomotor ataxia, and no 
confusion can arise from this course, so long as we bear in mind the 
relation which it bears to the more exact pathological designation. 

Although other writers, and especially Romberg, 1 had described a 
disease answering to that now generally known as locomotor ataxia, we 
are mainly indebted to Ducbenne 2 for giving a full and distinct ac- 
count of an affection which, before his studies, had scarcely attracted 
attention. Since then, the morbid anatomy, the pathology, and the 
symptomatology, have been so thoroughly studied by Charcot, Pierret, 
TVestphal, and others, whose labors will be presently more specifically 
referred to, that the disease in question may be said, with truth, to be 
one of the most thoroughly understood in the whole range of medical 
science. 

Symptoms. — Locomotor ataxia has no uniform set of initial sjrnip- 
toms. Sometimes it begins with dull, heavy pains in the small of the 
back or other part of the spinal column, which are very soon followed 
by sharp, electric-like pains, which shoot down the limbs along the 
course of the nerves, and which are very generally taken by the patient 
for twinges of neuralgia or rheumatism ; or it may be first manifested 

lu Lehrbuch der Nervenkrankheiten," Berlin, 1840; also, "Sydenham Society's 
Translation," London, 1853. 

! " De l'ataxie loeomotrice progressive," Archives Generates de Medecine, 1858; also, 
'* De 1' electrisation localisee," Paris. 1861. 



568 DISEASES OF THE SPINAL CORD. 

by a feeling of constriction around the body like that which is so com- 
mon in acute myelitis. 

Again, the first symptoms are cerebral, and may consist of attacks 
of vertigo, pains either in the front or back of the head, epileptic fits, 
disturbances of vision, such as diplopia, ptosis, and defective accom- 
modation. In this form the pupils are contracted often to mere points, 
or occasionally they will be found to be, one contracted, and the other 
dilated. 

At other times the stomach and bowels are disordered ; vomiting is 
frequent, and there may be diarrhoea or obstinate constipation. Or, 
finally, the initial phenomena may be connected with the sensibility, 
giving rise to anaesthesia, and the various abnormal sensations con- 
nected therewith. 

In whatever way it may begin, locomotor ataxia is soon chiefly 
manifested by disorders of motility, but inquiry reveals the fact that 
these are in reality secondary, being dependent upon the diminished 
sensibility which always exists. As this is the essential feature of the 
disease, I propose to inquire into its characteristics at some length. 

If the lesion, as it usually does, exists in the dorso-lumbar region of 
the cord, the first evidences of anaesthesia or of perverted sensibility 
are noticed in the feet. A common feeling is as if the toes are too 
large for the shoe, or as if pieces of some plastic material are between 
them. Sometimes there are burning pains in the soles of the feet, and 
very generally u pins and needles " and other forms of numbness. A 
curious symptom is that, not only is the sensibility lessened, but the 
transmission of sensitive impressions to the brain does not take place 
with the normal degree of activity. I have noticed this phenomenon in 
rather more than half the cases that have come under my observation. 
In a lady, now a patient, a pin stuck into the calf of the leg is not felt 
for fourteen seconds on the right side and sixteen on the left. In a 
patient with posterior spinal sclerosis, under treatment in the New 
York State Hospital for Diseases of the Nervous System, if the feet were 
put into hot Water the sensation was not felt for almost three minutes. 
As he said, " My feet might be scalded till the flesh dropped off and I 
would not know it till the mischief was done. Then I should feel it 
sharply." The explanation of this symptom is to be found in the fact 
that the conducting power of the posterior columns is lessened by the 
lesion, and hence the brain does not receive in the usual time the im- 
pressions made upon the nerves. 

The ability to feel pain is therefore diminished, but there is, besides, 
a marked abatement of the tactile sensibility. The extent of this can 
only be accurately measured by the aesthesiometer. When this instru- 
ment is used, we find that the two points can be widely separated and 
a single impression only be felt on parts of the body which in the nor- 
mal condition would give the sensation of two points at a much less 



PROGRESSIVE LOCOMOTOR ATAXIA. 569 

Histance apart. A gentleman from Virginia consulted me recently, in 
whom I diagnosticated locomotor ataxia, and who, instead of being able 
to perceive the two points with the end of the index-finger, when the 
twelfth of an inch apart, could feel but one point, though the two were 
separated to the extent of an inch and a half. Sometimes, even in the 
early stages of the disease, the loss of sensibility is so great that the 
patient hardly feels the points at all. 

This loss of sensibility gives rise to some curious sensations, espe- 
cially in the soles of the feet. These are usually such as might be pro- 
duced by the interposition of some substance between the foot and the 
shoe, or between the shoe and the ground. One patient feels as if he 
has cushions on the soles of his feet, another as if bladders of air are 
interposed, another as if he is constantly treading on sticks, or, if riding 
in an omnibus, as if the hem of a lady's dress had got under his feet, 
and one a short time since described the sensation to me as being like 
that which he thought he would feel if his feet had been dipped into 
tar, and then into sand. 

In some-cases the ability to distinguish differences of temperature, 
or to appreciate the sensations produced by the application of hot or 
cold bodies to the skin of the affected parts, remains, but this is not, as 
some authors assert, a constant phenomenon, for in the majority of 
cases the sensations produced by heat or cold are just as unappreci- 
able as those caused by any means capable of giving rise to sensitive 
impressions. 

But the symptoms by which locomotor ataxia is recognized most 
readily are those which relate to motility, and the phenomena often 
make their appearance at a very early stage of the affection. At 
that time there is no loss of motor power, but there is an inability 
to coordinate the muscles — to bring them to harmonious action, and 
thus to execute with precision the various voluntary movements. Thus, 
in the act of standing, a great many muscles are simultaneously made to 
contract, and each one to just that necessary degree which is essential 
to maintain the body in the erect posture. Very often the first 
evidence of any motor trouble is experienced in regard to this faculty 
of standing. This impediment is, however, not one of paralysis, for, if 
the patient looks at his feet, he has no more trouble in standing alone 
than a perfectly sound man. 

A gentleman connected with the city government of Brooklyn con- 
sulted me a short time since for an affection which was very evidently 
locomotor ataxia. The first indication of disease, as he informed me, 
was that it had been his habit, while at his morning ablutions, to shut 
his eyes, and he had noticed, about two months previously, that wh^n 
he did so he could not maintain his equilibrium. When he visited me 
he was unable to stand with his eyes shut, and his gait was perfectly 
characteristic of locomotor ataxia. 



570 DISEASES OF THE SPINAL CORD. 

Before the locomotion of the patient becomes obviously affected, ho 
experiences inconvenience in placing his feet upon small surfaces. 
Thus, when he attempts to enter a carriage, he finds it difficult to guide 
his foot to the step, and in mounting a horse he cannot readily hit the 
stirrup. A gentleman from Maryland, who is now a patient of mine, 
and who is affected with the disease in question, tells me that among 
the first symptoms which he noticed was the difficulty he experienced 
in putting his foot into the stirrup. He was obliged to use his hand as 
a guide. A like trouble is frequently experienced in ascending a stair- 
case. 

The gait of a person suffering from locomotor ataxia is very much 
changed from that which is natural. Instead of the foot being placed 
upon the ground with an easy motion, the heel a little in advance of 
the sole, and the latter gliding down gently, the leg is, as it were, jerked 
forward, the heel comes down suddenly, and the sole follows, at a con- 
siderable interval, with an abrupt flapping motion. In ordinary walking 
the placing of the foot on the ground consists of one movement — there 
being no stoppage between the touching of the ground by the heel and 
the planting of the sole of the foot; but, in the gait of a person affected 
with posterior spinal sclerosis, the foot is placed on the ground by two 
distinct movements, one for the heel and another for the sole of the 
foot. 

But, besides these irregularities of the progressive movements, there 
are others which are likewise notable. The leg is not carried directly 
forward, but is thrown out a little from the median line, and this gives 
the patient a motion like that of one walking on a tight-rope, and bal- 
ancing himself with a pole. The object of this movement is doubtless 
to widen the base, and thus to enable the patient to preserve more 
readily his centre of gravity within it. In standing, he, for the same 
reason, always separates the feet to a greater than normal distance. 

In walking or standing, it will be observed that the patient affected 
with sclerosis of the posterior root-zones of the spinal cord keeps his 
eyes fixed on his feet, or on the ground a little distance in advance. 
He is obliged to do this for the reasons — which with others will be 
more fully considered under the head of pathology — that the sensibility 
of the soles of the feet being diminished, and the muscular sensibility 
being also lessened, he is deprived, to a great extent, of the chief means 
by which he was formerly enabled to recognize the position of his feet, 
and of the dynamic condition of his muscles. He hence is obliged to 
make use of another sense — his vision — in order to obtain the necessary 
information. Therefore, when he shuts his eyes, or is obliged to walk 
in the dark, he is deprived of the assistance of his eyesight, and, having 
only his diminished tactile and muscular sensibility to guide him, moves 
in an exceedingly timid and disorderly manner, or else is unable to walk 
at alL 



PROGRESSIVE LOCOMOTOR ATAXIA. 571 

Under some circumstances he is unable to go forward, even with 
the assistance of his eyesight. Experience has taught him that he can- 
not rely on very important senses, which formerly he implicitly trusted. 
He loses c6nfidence in them, and is not reassured, even with vision to 
assist him. He therefore uses extraordinary caution in walking over a 
tiled floor, on the ice or snow, in descending a staircase, or in crossing 
a street crowded with vehicles. In a recent clinical lecture, 1 delivered 
to the class of the Bellevue Hospital Medical College, I called special 
attention to this phenomenon of loss of confidence, and adduced several 
cases in illustration of this point. 

That there is little paralysis of motion to account for these abnor- 
malities, can be readily show r n by a few inquiries and experiments. 
Thus it will ordinarily be found that the patient who is unable to stand 
with his eyes shut, or take a step in the dark, can push strongly with 
his legs, or Walk a short distance with a good deal of vigor. He is still 
good for a " spurt," but long-continued muscular effort fatigues him. 

When the lesion is above the origin of the nerves which go to form 
the brachial plexus, the upper extremities are the seat of symptoms 
which are similar to those described as manifesting themselves in the 
legs. There are numbness and other indications of anaesthesia, together 
with more or less difficulty in coordinating the muscles into harmonious 
action. The patient finds that the ends of his fingers have lost, to some 
extent, their acute tactile sensibility, and that there is restraint in the 
management of the fingers. He experiences these difficulties in button- 
ing his clothes, in picking up a pin, in writing, and in other actions 
requiring nice manipulation. If he attempts, for instance, to carry a 
glass of wine to his lips, he spills a portion of the contents ; and, if told 
to place his finger on any particular part of his face, the movement is 
accomplished with a wabbling motion, and the finger is darted suddenly 
to the part as it approaches it. All persons possess a knowledge of 
where the different parts of their bodies are situated, which does not 
depend upon the sense of sight, although probably acquired by that 
sense and experience. There is such an intimate and exact relation be- 
tween the ends of the fingers and the cutaneous surface of the body 
that, if a spot no bigger than the head of a pin be made with a pencil 
on the forehead, a person can close his eyes and touch it with the end 
of his finger without difficulty every time he makes the attempt. He 
can also, with the eyes shut, carry the end of his fingers straight to the 
tip of his ear, the middle of his eyebrow, or any other part of his body 
within reach. A person, however, laboring under sclerosis of the pos- 
terior root-zones of the spinal cord, cannot do any of these things. He 
loses, at a very early period of the disease, that intimate topographic? 1 
relation -which exists between the ends of the fingers and the rest of the 

1 " Clinical Lectures on Diseases of the Nervous System," Journal of Psychological 
Medicine^ January, 1871. 



57*2 



DISEASES OF THE SPINAL CORD. 



body ; and hence, when he closes his eyes, and attempts to put the tip 
of his index-finger on the end of his nose, he misses his aim, sometimes 
by as much as two or more inches. 

M. Onimus ' has called attention to the fact that important indica- 
tions are afforded by an examination of the handwriting of ataxics, the 
defective power of coordination being well shown even when the eyes 
are open, but being still more strongly manifested when they are shut. 
The difficulty which they experience is in making the round letters, 
such as «, c, and o. Besides the incoordination there is a jerking 
movement of the pen, and a kind of impulse to continue writing after the 
word is finished. Finally, when the ataxia of the arm is at its height, 
there is an impossibility of writing a single word, and we obtain only 
a set of traces confused and without order. I am able, after many ex- 
periments, to confirm 
FlG - 73 - the foregoing obser- 

vations. In Fig. 73, 
a, is seen the attempt 
of a patient with his 
eyes open, and look- 
ing at his pen, to write 
the word " Civiliza- 
tion." At b is a like 
attempt made w^hen 
the eyes were shut. 
As in the legs, when the lesion is so low down in the cord as only 
to affect them, there is no well-marked paralysis. The grip of the pa- 
tient is strong, and the dynamometer shows the existence of consider- 
able strength. He is, however, not capable of continued muscular 
effort ; and, though he may be able to lift several hundred pounds, or to 
carry another person around the room, his muscles are exhausted with 
the gradual and regular expenditure of a much less amount of force. 

A phenomenon is often noticed as regards the upper extremities, 
which also exists with the lower, hut which cannot be so readily mani- 
fested — and that is, that the patient loses the ability to distinguish 
even considerable differences between weights. In the normal condi- 
tion, if two weights, differing in the ratio of thirty-nine to forty, are 
put one in one hand and one in the other, the difference is perceived 
without difficulty. The lower extremities, according to Jaccoud, are 
not so sensitive, and cannot distinguish a less difference than from 
about fifty to seventy grammes. 

A person affected with locomotor ataxia, due to sclerosis of the 
posterior root-zones above the origins of the nerves which form the 
brachial plexus, may have an ounce-weight put into his hand, and 

1 Gazette medicate, February 21, 1874 ; also, Chicago Journal of Nervous and Mental 
Diseases, April, 1874, p. 254. 




PROGRESSIVE LOCOMOTOR ATAXIA. 



573 



if in a few seconds it be removed, and one of half an ounce be substi- 
tuted, he will not be able to tell correctly which is the heavier. Or 
both hands may be extended, and the two weights placed simul- 
taneously in them. The eyes should, of course, be closed. Some- 
times less differences can be perceived, but ordinarily greater ones 
are not distinguished. In the case of a gentleman now under my 
charge, there is an impossibility of telling which of two pieces of 
lead, the one weighing one ounce and the other a pound, is the heavier. 
Spiith l states that, in a case under his charge, the patient could not 
distinguish between two weights, which differed as one to one hundred. 
No means for measuring the extent to which the patient is able to 
determine the state of muscular contraction is at all comparable to the 
dynamograph. The range of its usefulness is, however, limited — owing 
to the fact that posterior spinal sclerosis is not very frequently seated 
high enough in the cord to affect the muscles of the upper extremities. 
When the lesion is not above the origin of the nerves which go to form 
the brachial plexus, the line is straight, as in the accompanying figure, 



Fig. 74. 



which represents the tracing made by a patient suffering from sclerosis 

of the posterior root-zones in the lower dorsal region of the cord. But, 

when the seat of the disease in the cord is anywhere between the fifth 

cervical and first dorsal vertebrae, the ability to maintain a uniform 

degree of pressure is impaired, and lines resembling the following are 

produced : 

Fig. 75. 




Both the above were made by the same patient, the upper with 
the right and the lower with the left hand. He was perfectly confi- 
dent, till I showed him the tracings, that he had exerted a uniform 
pressure while the paper was traversing the pencil. 

1 " Beitrage zur Lehre von der Tabes dorsalis," Tubingen, 1864. 



574 DISEASES OF THE SPINAL CORD. 

Under the name of barrcsthesiometer, Eulenberg 1 has described an 
instrument for estimating the sense of pressure, by means of which very- 
accurate determinations can be made for different parts of the body. 
He succeeded in demonstrating a considerable impairment of the sense 
of weight in the great majority of cases of locomotor ataxia exam- 
ined, even when sensibility to pain, tickling, or electric irritation, was 
but slightly affected, and the sense of temperature was normal. 

The reflex excitability of the skin is generally notably increased. 
The touch of the bedclothes, or even the rubbing of one leg against 
the other, is sufficient to cause strong contractions. Involuntary 
movements of the limbs, independent of those due to reflex excita- 
tions, are rarely met with. 

A symptom first pointed out by Westphal 2 is the absence or nota- 
ble diminution of the reflex excitability of the tendons. It is generally 
best exhibited by causing the patient to cross one leg over the other 
and then to strike with the side of the hand the tendon of the quadri- 
ceps extensor just below or just above the patella. It will be found 
that there is very slight and often no movement whatever of the leg. 
In the healthy subject, involuntary extension of the leg at once takes 
place. This symptom, though occasionally absent, as I have found, is 
yet so generally present, even in the early stage of locomotor ataxia, 
as to make it a sign of considerable diagnostic importance. 

The electro-muscular contractility is generally increased. In some 
few instances I have found it normal, and in still fewer diminished. 
There are no polar degenerative reactions. 

It has already been mentioned that there are frequently ocular 
troubles. These generally occur among the early symptoms, and relate 
either to vision, to the movements of the eyeball, or to both. Indeed, 
the very first symptoms may be connected with the eye or the nerves 
supplying its muscles. Thus there may be amaurosis due to gray 
atrophy of the optic nerve, or of the disk, a condition readily detected 
by the ophthalmoscope ; or the third pair of nerves may be involved, 
causing ptosis, divergent strabismus, and dilatation of the pupil ; or 
the sixth pair of nerves alone may be affected, causing convergent 
strabismus ; or there may be only contraction of the pupil and promi- 
nence of the eyeball from the irritation propagated from the cilio- 
spinal centre through the sympathetic nerves. In the majority of 
cases the iris loses its reflex action to light, but, as Argyll-Robertson 
first pointed out, still retains the power of contraction and dilatation 
for accommodation. These ocular troubles never take place in sclero- 
sis of the posterior root-zones existing below the cilio-spinal centre — 
the upper dorsal region of the cord. 

1 Allg. Med. Cent.-Zeitung, No. 93, 1869; also, Journal of Psychological Medicine^ 
October, 1870, p. 622. 

2 "Archiv fur Psychiatrie und Nervenkrankheiten," B. v., s. 819. 



PROGRESSIVE LOCOMOTOR ATAXIA. 575 

Galezowski l has called attention to a very important fact in con- 
nection with the ocular disturbances of ataxics, and that is, the loss of 
the ability to distinguish certain tints and colors. Thus patients affect- 
ed with locomotor ataxia, and who are at the same time amaurotic 
from gray atrophy of the optic nerves, are unable to distinguish the 
secondary tints of the scale (1 to 5, Plate F), and lose the perception of 
red and of green. The perception of yellow and blue is not lessened ; 
on the contrary, it appears in some cases to be rendered abnormally 
delicate. I have frequently verified the extreme value of these tests, and 
have often observed the phenomena referred to when there was no other 
disturbance of normal vision, so far as all type-tests were concerned. 

Another organ liable to functional derangement and even organic 
disease as effects of locomotor ataxia is the heart. Attention was first 
directed to this point by Berger and Rosenbach, 2 who, in a monograph 
based on seven cases, arrived at the conclusion that aortic insufficiency 
was the condition induced. But in a recent paper on the subject of 
the relation between locomotor ataxia and cardiac lesions, M. Gras- 
set 3 shows, from two cases occurring in his own experience, and the 
citation of fifteen others from different writers, that the influence is 
not such a restricted one as supposed by Berger and Rosenbach, and 
that the influence is such as would be produced by acute suffering of 
any kind. He shows very conclusively that there is no direct relation 
between the spinal affection and the heart, but that the agonizing 
pains which the patient affected with locomotor ataxia usually suffers, 
are the cause of the heart-troubles. To use his own language : " Ex- 
periments prove the undoubted influence of peripheral excitations and 
painful sensations on the heart. They show that it is possible that, with 
man, pains, if long continued, affect the heart in an abnormal way and 
induce disease of the organ. Physiology simply indicates the possi- 
bility • clinical experience establishes the reality." 

The disturbances in the healthy action of the stomach and intes- 
tines, which have already been alluded to as common initial symptoms, 
are sometimes very distressing. As the pains in the limbs are often 
taken for evidences of neuralgia or rheumatism, so these gastric and 
intestinal troubles are frequently regarded as indicating the existence 
of dyspepsia. I have had a number of patients under my charge who, 
with double vision, ptosis, contracted or unequal pupils, incoordination, 
and the other symptoms of locomotor ataxia, had been told that " it 
was all dyspepsia," because vomiting and gastric pain were prominent 

1 " Du diagnostic des maladies des yeux par la chromatoscopie retinienne," etc., Paris, 
1868; also, "Echelles typographiques et chromatiques pour l'examen de l'acuite visuelle,'' 
Paris, 1874. 

2 " Ueber die Coincidenz von Tabes Dorsalis und Insufficienz der Aorten-Klappen," Ber- 
liner Jclin. Wochenschrift, No. 27, 1879, p. 402. 

••"Ataxie locomotricc et les lesions cardiaques," Montpellier Medical, Juin, 1880. 



576 DISEASES OF THE SPINAL CORD. 

features of the disease. These symptoms are also due to the relations 
of the sympathetic nerves with the spinal cord, and are not present in 
cases where the lesion is low down in the lumbar region. 

When, however, this part of the cord is involved, there are very 
remarkable disorders of the genital system. These consist of frequent 
nocturnal emissions with or without erections, or of an inordinate desire 
for sexual intercourse. A gentleman who consulted me a few weeks 
ago, and who was affected with the disease in question, informed me 
that he had several times had as many as eight seminal emissions in 
one night, and that his sexual desire was almost inextinguishable. 

Paralysis of the bladder is a common circumstance, and the sphinc- 
ter is not infrequently likewise affected. The bowels are usually obsti- 
nately constipated. 

The feeling of constriction around the body, which is so common a 
symptom in acute myelitis, and which is met with in other organic 
affections of the cord, is rarely absent in cases of sclerosis of the pos- 
terior columns. 

Although the course of the disease in the great majority of cases is 
onward to a fatal termination, there are often periods of remission, as 
in other spinal affections, and it rarely happens that the duration is not 
several years. A gentleman from Westchester County, in this State, 
has been affected for over twenty years, and still walks tolerably well. 
Another from Boston had been subject to the disease for over twelve 
years. When I first saw him he could not stand with his eyes shut, 
had the characteristic ataxic gait, was subject to genital and urinary 
troubles, but yet was no worse than he had been six years previously. 
He visited me again in October, 1875, walking as well as when I saw him 
originally, but still subject to the electric-like pains in as great degree 
as ever. Another, from Pittsburg, has been in a stationary condition 
for several years ; and another, from Binghamton, in this State, remains 
about as he was three years ago. I could easily cite twenty others 
whom I occasionally see professionally, who hold their own, and who 
have been affected for from five to ten years. Romberg gives the 
average duration at from ten to fifteen, Jaccoud at from six to eight, 
and all authors' agree that the course is slow. Of the many patients 
affected with sclerosis of the posterior columns of the spinal cord who 
have been under my charge during the last ten years, five only have 
as yet died, so far as I am aware. Of these, one had been affected 
seven years, one eight years, two about ten years, and one eight and a 
half years. There are several cases now under my charge in which the 
affection has existed longer than either of these terms. 

The advance of the disease in the cord causes an aggravation of all 
the symptoms, and the appearance of others not previously noticed. 
The loss of motor power is now a prominent feature, the muscles be- 
come atrophied, bed-sores make their appearance, there is anasarca, and 



PROGRESSIVE LOCOMOTOR ATAXIA. 577 

the patient, if not carried off by some intercurrent affection, dies of the 
extreme exhaustion induced by his disease. 

Among the anomalies of sclerosis of the posterior root-zones of the 
spinal cord, the joint affections are especially worthy of attention. 
Their connection with posterior spinal sclerosis was first indicated by 
Charcot. 1 Previous to his observations, they had been noticed, but they 
were ascribed to an intercurrent rheumatism, and, many years before 
locomotor ataxia was recognized as an independent disease, the asso- 
ciation of spinal disease with inflammation of the joints was pointed 
out by Prof. J. K. Mitchell, 2 of Philadelphia ; and his son, Dr. S. Weir 
Mitchell, with Drs. Morehouse and Keen, 3 had also related cases in 
which wounds of the spine had been followed by arthritis. Since 
Charcot's paper was published, Dr. Benjamin Ball 4 has cited cases of 
like affections coexisting with locomotor ataxia. In the cases in ques- 
tion there is no fever, redness, or pain. Generally these accidents dis- 
appear without leaving permanent organic changes behind them, but 
in some cases the head of the bone may be absorbed, and spontaneous 
dislocation be the result. 

Of the cases of locomotor ataxia which have come under my obser- 
vation, in nine only were there any troubles of the joints. 

Death may take place either as the direct consequence of the lesion 
of the spine, or as the result of some intercurrent affection, such as 
pneumonia, dysentery, phthisis, or cystitis, or by disturbances of respi- 
ration and circulation, or paralysis of the muscles of deglutition by 
the extension of the disease upward, so as to reach the phrenic nerves, 
or medulla oblongata. 

A psychical form of locomotor ataxia mentioned by some authors 
can scarcely be said to exist. It is true that some patients are pecul- 
iarly subject to mental depression, and to attacks of temporary excite- 
ment, with wakefulness ; but the rule, according to my experience, is 
that by far the greater number preserve a very calm and equable 
frame of mind, and such is the conclusion of Steinhal 6 and Erb. 6 

But mental disorder of a very decided character is occasionally, 
though rarely, developed toward the latter stages of locomotor ataxia. 
I have not, however, been able to ascertain that this is particularly 
liable to assume any special form. It may be intense melancholia, or 

" Sur quelques arthropathies qui paraissent dependre d'une lesion du cervcau ou 
de la moelle epiniere," Archives de physiologie, No. 1, January, 1868, p. 161. 

2 American Journal of the Medical Sciences, vol. viii., 1831, p. 55. 

1 " Gunshot- Wounds and other Injuries of Nerves," Philadelphia, 1864. 

1 "On Diseases of the Joints connected with Locomotor Ataxy," Medical Times and 
Gazette, October 31, 1868. 

■ " Beitrage zur Geschichte und Pathologie der Tabes Dorsalis," Hufcland's Journal, 
Hand 93, 1844. 

6 " Graue Degeneration der Hinterstrange," Ziemssen's Handbuch, elfter Band, zweite 
Halfte, p. 184. 

38 



578 DISEASES OF THE SPINAL CORD. 

general mania, or general paralysis of the insane. It is necessary to 
bear in mind, especially as regards the last-named complication, that 
it is altogether different from a brain-disease with ataxic phenomena. 
There is a form of general paralysis of the insane in which there are 
difficulties of coordination and other tabetic symptoms, but here the 
cerebral manifestations are first in order ; whereas, in locomotor ataxia, 
the spinal disorder is the primary trouble, and the cerebral altogether 
secondary. Westphal 1 was the first to direct attention to the ataxic 
form of general paralysis of the insane, and to show that the disorders 
of movement which are exhibited are due to degeneration of the pos- 
terior columns of the spinal cord. 

Several instances of mental disorder supervening toward the ter- 
mination of locomotor ataxia have come under my observation, and in 
one of them the development was so rapid as to preclude the idea that 
it was due to any extension of the disease directly to the brain. The 
form of mental derangement in this case was acute mania, and the 
patient died, after a paroxysm of intense excitement, in a condition of 
profound coma. 

In another case there were repeated epileptiform convulsions, with 
stupor during the intervals, and in which latter condition death ensued. 

Friedreich 2 has called attention to an affection of the spinal cord 
occurring very rarely in children, which he regards as a hereditary or 
family form of locomotor ataxia, but which, from an experience of four 
cases, and detailed descriptions of six others occurring in the practices 
of Drs. W. C. Warren, of Holly Springs, Mississippi, and E. S. Coleman, 
of Hollywood, Arkansas, I am disposed to think is not locomotor ataxia, 
but a hitherto unrecognized spinal disease. It begins in early life, and is, 
at least in the early stages, not so much characterized by incoordination 
as by muscular weakness. In the cases I have witnessed, the children, 
brothers in two instances, presented the appearance of old men, but 
were able to walk as well with the eyes shut as with them open, and 
to stand with closed eyes without any unusual swaying of the body. 
In none of the cases was there any hereditary tendency, but, as I have 
said, my cases are two pairs of brothers. Dr. Warren's cases, three in 
number, were children of the same parents ; as were also Dr. Coleman's 
three cases. All my cases are males ; of Dr. Warren's cases two were 
boys and one a girl ; of Dr. Coleman's cases all were boys. Friedreich 
is of the opinion that this form is more common in girls than in boys. 
I think it somewhat doubtful whether the cases he cites are of the 
same character as those which have come to my knowledge, and I re- 
frain from any further discussion of the subject till I have more thor- 

1 " Tabes Dorsualis und Paralysie universal progressive," Zeitschrift fur Psychiatrie, 
Band xx., 1863; und xxi., 1864. 

2 " TJeber ataxia mit besonderer Beriicksichtigung der hereditaren Fc-rmen," Virchou^s 
Archiv, Band 68, 1876 ; Band 70, 1877. 



PROGRESSIVE LOCOMOTOR ATAXIA. 579 

oughly studied the symptoms and pathogeny, through the instances 
within the range of my own observation. 

Causes. — I have been very unsuccessful in my efforts to ascertain 
the cause in the greater number of persons affected with progressive 
locomotor ataxia who have been under my observation. The opinion 
is very prevalent that it is generally the result of excessive venereal in- 
dulgence ; and, although this is undoubtedly sometimes a cause, it cer- 
tainly is not so common a one as is generally supposed. I have care- 
fully inquired into the etiology of all the cases I have seen, and have 
only been able to assign inordinate sexual indulgence as the cause in a 
very small proportion. The impression has probably arisen from the 
fact that there are frequently aberrations of the sexual function as phe- 
nomena of the disease. Injuries and exposure to cold and dampness 
were apparently the causes in some cases, standing in a constrained po- 
sition — three cases in railway conductors — in others, the excessive use of 
alcoholic liquors in a larger proportion, and syphilis in probably one- 
twentieth of the cases. In the majority, however, no cause can reason- 
ably be assigned. As regards the predisposing causes, it is certainly 
more common in men than in women — four cases only in my experience 
pertaining to the female sex. The age from twenty-five to forty is that 
in which it most frequently appears. There seems to be no direct 
hereditary influence to the disease. 

Diagnosis. — A consideration of the symptoms detailed in the fore- 
going pages will prevent posterior spinal sclerosis from being confound- 
ed with any other affection of the spinal cord. It may, however, be 
difficult at times to discriminate between it and the lesions of the cere- 
bellum, and the distinction has frequently not been made by very skill- 
ful diagnosticians. At one time Duchenne held the view that locomo- 
tor ataxia was really the result of a lesion of the cerebellum, but he 
subsequently * retracted this opinion, and accepted the doctrine that 
the spinal cord is the seat of the disorder. 

In a recent memoir 2 I have endeavored to point out the differences 
between cerebellar disease and the affection now called posterior spinal 
sclerosis. In that essay I have said : " Derangement of locomotion 
certainly does result from injury or disease of the cerebellum. Experi- 
mental physiology, as well as pathology, proves this. Beyond a doubt 
the disorder is, however, clearly due to vertigo. There are, moreover, 
headache, vomiting, and eventually in some cases hemiplegia, generally 
of the opposite side to that of the cerebellar lesion, a fact at variance 
with Larrey's assertion. The gait of a person thus affected is exactly 

1 "Diagnostic differential des affections cerebelleuses et de l'ataxie locomotrice pro- 
gressive," Gazette hebdomadmre, 1866. 

2 " The Physiology and Pathology of the Cerebellum," Journal of Psychological Medi 
cine, April, 1869. 



580 DISEASES OF THE SPINAL CORD. 

similar to that of a drunken man. As Carre says, the movements are 
not abrupt, jerking, and exaggerated, as they are in locomotor ataxia. 
They are more uncertain, and do not depend upon any defect of co- 
ordination, but upon weakness of the voluntary power. 

" When either of the peduncles of the cerebellum is affected there 
is an irresistible impulse to go sideways, and sometimes gyratory move- 
ments are produced." 

The characteristic symptom of cerebellar lesion is vertigo ; and, 
although this is sometimes met with in sclerosis of the posterior root- 
zones, it is not a prominent feature, and is rarely present at all except in 
the very earliest stage. 

In the cerebellar lesions the cutaneous sensibility is unimpaired, 
whereas in posterior spinal sclerosis it is always diminished. 

A patient with disease of the cerebellum can stand and walk better 
with his eyes shut than with them open, for the vertigo is not in the 
former condition felt to the same extent. The reverse is true of loco- 
motor ataxia. The history of the case will also serve as a good guide 
to the diagnosis. In the latter or even in the developed stage of loco- 
motor ataxia it would be difficult to mistake it for any other affec- 
tion. 

Prognosis. — The prognosis is no more favorable than that of ante- 
rior or lateral spinal sclerosis. A few cases are cured, more are relieved, 
but the great majority go on unchecked. Of the cases which have come 
under my observation, seven were cured, and they were subjected to 
treatment from a very early stage. Of these, four were probably of 
syphilitic origin, but in the other three no such cause was at all probable. 
One of them was a woman. 

The cases in which amelioration has been produced are more numer- 
ous. In fact, it is not at all uncommon to succeed in retarding the on- 
ward progress of the disease, and of thus prolonging the life of the 
patient. 

Morbid Anatomy. — Within the last few years many very important 
contributions have been made to the morbid anatomy of locomotor 
ataxia mainly by the pathologists of that great French school of the 
Salpetriere with Charcot at its head. For the complete understanding 
of these a few words relative to the normal anatomy of the parts con- 
cerned are necessary. 

In embryonic and early infantile life the posterior columns are di- 
vided into two unequal parts by a fissure extending from the angle formed 
by the posterior median fissure and the posterior commissure of gray 
matter. The internal or median part is wedge-shaped, is of greater extent 
in the cervical region than in the dorsal, and greater in this than in the 
lumbar. It is called the posterior median column, or the column 
of Goll. 

The external part of the posterior column is all that region 



PROGRESSIVE LOCOMOTOR ATAXIA. 581 

bounded externally by the posterior horn of gray substance and in- 
teriorly by the posterior median columns. It is called the poste- 
rior external column, or the posterior root-zone, or the column of 
Burdach. 

In adult life the fissure separating these two regions no longer ex- 
ists, but its situation is generally marked by a furrow on the periphery 
of the cord, and a histological difference exists between them, in that 
the posterior median columns contain a greater amount of connective 
tissue than do the posterior external columns, and the nerve-fibres in 
them are long and continuous, while those in the latter contain many 
short fibres, which, after passing upward or downward for a short dis- 
tance, leave it ; the majority of them entering the posterior horn of 
gray substance, the minority terminating in the posterior median 
column. 

Now, although it often happens that both these subdivisions of the 
posterior columns are the seat of the alteration giving rise to loco- 
motor ataxia, it has been very positively shown that the essential 
lesion is that of the posterior external column, and that it is to the 
disease of these regions that the majority of the peculiar symptoms of 
locomotor ataxia are due. 

The posterior internal columns transmit the muscular sense for the 
lower limbs and trunk only. The muscular sense tract for the upper 
extremities probably lies in the median portion of the posterior exter- 
nal columns. It is therefore possible, if the ataxia is limited to the 
upper extremities, to find the lesion confined to the posterior external 
columns. 

This point has been determined by a case very thoroughly investi- 
gated by Pierret, 1 in which a woman named Moli suffered from the 
electric-like pains, and incoordination of locomotor ataxia, which were 
mainly experienced in the upper extremities. On post-mortem exam- 
ination that part of the cord — the cervico-dorsal — in relation with the 
upper extremities was found to be sclerosed in a thin lamina existing 
only in the posterior external columns. The posterior median columns 
were perfectly healthy. 

In another case the same observer had the opportunity of confirm- 
ing the view that the posterior median columns do not transmit sen- 
sory impressions from the upper extremities. A woman (Cutta) had 
suffered for many years with electric-like pains in the lower extremi- 
ties, plantar anaesthesia, and incoordination. Standing and walking 
were impossible. In late years she had experienced constricting pains 
around the body. The superior extremities were not in the least in- 
volved. On post-mortem examination the posterior columns in the 
lumbar region were sclerosed throughout their whole extent, except 

1 " Sur les alterations de la substance grise do la moelle epiniere dans l'ataxie loco- 
motrice," etc., Archives de physiologie, 1870, p. 597. 



582 DISEASES OF THE SPINAL CORD. 

that on each side a little islet of healthy tissue remained. At the 
sixth dorsal vertebra the sclerosed tissue was less extensive and almost 
entirely confined to the posterior median columns, the posterior ex- 
ternal columns only exhibiting on each side a little islet of sclerosed 
tissue. A little higher these islets disappeared, and the lesion was 
entirely limited to the posterior median columns. 1 

Now, if the posterior median column is not exclusively occupied 
by fibres transmitting sensory impressions from a lower level, we 
should not be able to account for the entire exemption of the superior 
extremities from all ataxic phenomena, for the posterior median col- 
umns in that part of the cord in relation with them were the seat of 
marked lesion. 

When the posterior median columns are the seat of marked dis- 
ease, it is more than probable that the lesion originates in the poste- 
rior external columns, and therefore affects the former secondarily. 
Pierret expresses the opinion, in which Charcot concurs, that the im- 
plication of the posterior median columns is a phenomenon analogous 
to that which produces an ascending median sclerosis as a result of 
partial myelitis, and that the lesion is only produced in those cases in 
which the morbid process is very strongly pronounced in the lumbo- 
dorsal region of the cord. 

As has been shown, the initial lesion of tabes begins in the poste- 
rior external columns. Now, it is through these columns that a large 
proportion of the sensory fibres pass immediately after their entrance 
into the spinal cord, and it is the slow inflammation and destruction 
of these fibres that give rise to the group of symptoms previously 
described. Sensory tracts in the cord degenerate upward, and usually 
degenerate slowly ; hence, as the disease generally begins in the lower 
segments of the cord, a considerable interval of time elapses before 
symptoms of the disease appear in the arms, and a still longer time 
before cerebral symptoms are observed. 

It is not always the case that the morbid process stops with the 
posterior columns ; the posterior horns of gray matter, the lateral 
columns, and even the anterior horns, may be reached. 

As to the spinal nerves, it will almost invariably be found that the 
posterior roots are atrophied and the sensory ganglia diseased. 

The intra-cranial lesions are important. Indeed, there is reason 
to think that they are often the starting-point of the disease. They 
have been very carefully studied by many observers, and the fact 
that one of the most striking of them — that of the optic nerve — can 
be observed with the ophthalmoscope, gives additional interest to the 
subject. 

The alteration which the optic nerves undergo is a slow progressive 

1 " Note sur la sclerose des cordons postericurs dans l'ataxie locomotrice progres- 
sive," Archives de physiologie, tome iv., 1871— '72, p. 364. 



PROGRESSIVE LOCOMOTOR ATAXIA. 583 

sclerosis, causing atrophy of the disks and of the nerves themselves. 
From the color which the nerves assume, the condition is known by 
ophthalmologists as gray degeneration. According to Leber, and Weck- 
er and Jaeger, the essential changes met with in gray degeneration of 
the optic nerve are a marked increase in the quantity of connective 
tissue, especially of the cell-elements, and the appearance of numerous 
grumous cells. The lesion is therefore of the same character as sclero- 
sis affecting the other parts of the nervous system. 

The ophthalmoscopic appearances have been so clearly stated by 
Wecker and Jaeger, 1 that 1 quote from them the following details : 

" The clinical characters are especially revealed by the particular 
appearance of the papilla and by the narrowing of the visual field. 

" An essential sign which we have claimed for the ophthalmoscopic 
image of gray degeneration, is the more or less complete absence of an 
atrophic excavation. It is of course easy to understand that such ex- 
cavation is much less apt to be formed when there is a substitution of 
cellular tissue than when, as in simple atrophy, the entire nervous struct- 
ure disappears. 

" In gray degeneration of the nerve the initial signs of the disease 
consist in a simple change in the color of the papilla without any exca- 
vation. It becomes pale, as is perceived by the examination of the 
erect image with Helmholtz's plates, and it assumes a more or less pro- 
nounced bluish tint. 

"With this change of color there is a coincident change in the 
transparency of the tissue of the disk. It becomes impossible to fol- 
low the central vessels in their ramifications ; they seem to be applied 
to the bluish-white tissue of the papilla, and the whitish sclerotic ring 
offers a marked contrast to the opaque tissue of the nerve." 

According to these authors, the ophthalmoscopic appearances in 
cases of gray degeneration are sufficiently characteristic to enable the 
diagnosis of locomotor ataxia to be made with certainty from them 
alone. This is, however, I am inclined to think, too positive a state- 
ment. We may, however, safely conclude that when they are coexist- 
ent with the disturbance of chromatic perception previously referred 
to ; when the pupils are contracted — they are dilated in ordinary optic 
neuritis and atrophy of the optic nerve — and especially when electric- 
like pains are present, we have as positive indications of the existence 
of locomotor ataxia as are desirable. 

Besides this atrophy of the optic nerve, there is another condition to 
which it is subject, as a consequence of a preexisting sclerosis of the 
posterior root-zones, and that is a chronic neuritis. This state is in- 
duced when the spinal lesion is seated in that part of the cord known 
as the cilio-spinal centre. The ophthalmoscope in these cases reveals 

1 " Traite des maladies du fond de l'oeil," Paris, 1870, p. lit. 



584 DISEASES OF THE SPINAL CORD. 

in the early stages the existence of choked disk, and subsequently sim- 
ple atrophic changes. This condition is not peculiar to locomotor 
ataxia, but may be caused by other chronic affections of the spinal 
cord. It is referred to by Dr. Clifford Allbutt ' in his excellent mono- 
graph as " simple or primary atrophy of the optic nerve, sometimes ac- 
companied at first by that slight hyperemia and inactive proliferation 
which make up the state I have called chronic neuritis. This sort of 
change I have never found as a result of spinal injuries, but I have 
often met with it in chronic degeneration of the cord, and in locomotor 
ataxy." 

Besides the optic, others of the cerebral nerves may be affected. 
Those most commonly involved are the third, the sixth, and the audi- 
tory; the lesion of this latter causing deafness and other disturbances 
of hearing. 

The lesions found in the brain never affect primarily the hemi- 
spheres. To be sure, it is sometimes the case that there are mental 
troubles, but they come on toward the close, and are probably the 
result of defective nutrition and sympathetic action. 

The other cerebral lesions, like that of the optic nerve, are in very 
intimate anatomical relation with the posterior columns of the cord. 
They are, therefore, met with in the lower cerebellar peduncles, in the 
restiform bodies, and in the optic thalami, and consist of degeneration 
and atrophy. 

The situations of the spinal lesions and their general character were 
well known to Romberg 3 before the researches of Duchenne, Charcot, 
and others. Thus, he states that he was present at the post-mortem 
examination of the cord of a former patient. The organ was reduced 
one-third in diameter, and the atrophy was confined to the lower part 
of the posterior columns. The posterior nerve-roots were also atro- 
phied, but the anterior columns were healthy. He was also acquainted 
with the fact that the cerebral nerves were similarly affected. 

Although it is probable that the sympathetic is atrophied in some 
part of its extent, in many cases of locomotor ataxia, the fact has 
not been demonstrated, except as regards one instance reported by 
Donnezan, in which a filament from the superior cervical ganglion was 
found atrophied. The ganglion itself was healthy. 

In the later stages of the affection the muscles may exhibit a con- 
dition of atrophy. In such cases their tissue will be found on micro- 
scopical examination to have undergone fatty degeneration and substi- 
tution to a greater or less extent. 

1 " On the Use of the Ophthalmoscope in Diseases of the Nervous System," etc., Lon- 
don and New York, 1871, p. 198. 

3 " Lehrbuch der Nervenkrankheiten des Menschen," " Sydenham Society Transla 
tion," London, 1853, vol. ii., p. 399. 



PROGRESSIVE LOCOMOTOR ATAXIA. 



585 



Fig. 76. 



Fig. 77. 




The morbid anatomy of the joint-affections which sometimes result 
from the spinal lesion consists in an accumulation of water in the 
synovial cavity, and a general oedema of the soft parts. The most 
common seat of this alteration 
is the knee, and next after that 
the shoulder. The hip, the el- 
bow, the wrist, and the smaller 
joints, may also be involved. 
Occasionally the trouble does 
not stop here, but the articulat- 
ing surfaces may become rough 
from atrophy of the proper 
bone-tissue, and eventually a 
considerable part of the osse- 
ous substance disappears, giv- 
ing rise to spontaneous laxation. 
The accompanying figures, from 
Charcot, illustrate the nature of 

the change. In Fig. 76 is represented the superior extremity of the 
healthy humerus, and in Fig. 77 the corresponding part of a humerus 
exhibiting the lesions produced by locomotor ataxia. 

Pathology. — The theory of posterior spinal sclerosis which is gen- 
erally held is, that the lesion impairs a faculty by which the muscles are 
brought into harmonious action — a faculty of coordination. According 
to this view, the first thing to be done was to locate this faculty in an 
organ, and Duchenne, with whom it originated, adopting the ideas of 
Flourens and others, placed it in the cerebellum, and therefore regard- 
ed what he designated progressive locomotor ataxia as a disease of the 
cerebellum. 1 Thus he said : " In conclusion, regarding the order of 
appearance, and the habitual progress of the symptoms which mark 
the three periods of progressive locomotor ataxia, we find that the 
central morbid action which produces the phenomena symptomatic of 
this disease begins in general in the motor nerves of the eye, and in 
the tubercular quadrigemina, extending thence to the superior and 
inferior cerebellar peduncles and finally to the cerebellum." 

As already stated, Duchenne has abandoned this view of the loca- 
tion. But, although it has been established by numerous post-mortem 
examinations that the cerebellum is not the seat of lesion in cases of 
locomotor ataxia, and although the differential diagnosis between dis- 
eases of the cerebellum and posterior spinal sclerosis has been very 
clearly made out, there are some who still hold the view that, although 
the cerebellum shows no traces of disease, and that, although the poste- 
rior columns of the spinal cord may be in a state of sclerosis, the symp- 
toms are the result of an interruption to the passage, from the cere- 
1 " De 1' electrisation localisee," deuxieme edition, Paris, 1861, p. 611. 



586 DISEASES OF THE SPINAL CORD. 

bellum through the posterior columns to the spinal nerves, of that force 
which coordinates the muscles into harmonious action. In the memoir 
to which reference has already been made, I have entered at length 
into the consideration of the question of the location of a coordinating 
faculty in the cerebellum, and have, I think, adduced sufficient facts 
and arguments to show that coordination is not one of its functions. 
Without going into a full account of the subject, a synopsis of the con- 
clusions arrived at will probably not be deemed out of place : 

1. The consequences of removal of the cerebellum, if the animal 
survives the immediate effects of the injury, are not enduring. This 
conclusion is supported by experiments by Flourens, 1 Harting, a Wag- 
ner, 8 Dalton, 4 myself, 5 and others. The physiological inference, of 
course, is, that, if the faculty of coordination resided in the cerebellum;, 
it ought to be permanently removed with the ablation of the organ. 

2. The entire removal of the cerebellum from some animals does 
not apparently interfere in the slightest degree even for a moment with 
the regularity and order of their movements. I have performed a num- 
ber of experiments with reference to this point, on different classes of 
animals. They prove very clearly that the cerebellum is not the gen- 
erator of coordinating power in all animals that have it: a fact in com- 
parative physiology which is fatal to the hypothesis that this is its 
function in man. 

3. The disorder of movements which results in birds and mammals 
Immediately after injury of the cerebellum is not due to any loss of 
coordinating power, but is the result of vertigo. 

If the cerebellum be removed from a pigeon it exhibits disorder in 
its movements, but a careful examination of the phenomena exhibited, 
shows that it is suffering from a vertiginous sensation. Even when 
placed upon its breast and allowed to remain at rest, there is a trem- 
bling and swaying of the body, such as is produced by alcoholic in- 
toxication. Exactly such symptoms can be caused by giving pigeons 
bread soaked in alcohol. 

4. The phenomena of cerebellar disease or injury, as exhibited in 
man, are not such as show any derangement of the t coordinating power. 

Many cases are on record which support this proposition. Andral 6 
states that, of ninety-three cases of cerebellar disease which he has 
studied, only one appeared to support the theory which locates the co- 
ordinating power in the cerebellum. 

1 " Recherches experimentales sur les proprietes ct les fonctions du systeme ner- 
veux," Paris, 1842. 

2 " Experimenta quaedam de affectibus leesionum in partibus encephale," 1826. 

3 " Nachrichten von der Universitat una der Konigl. Gesellschaft der Wissenschaften 
zu Gottingen" ; also, Journal de la physiologie de Vhomme et des animaux, Avril, 1861. 

4 American Journal of the Medical Sciences, January, 1861, p. 83 ; also, " Treatise on 
Human Physiology," fourth edition, 1867, p. 416. 

5 Op. tit., p. 24. 6 "Clinique medieale," seconde edition, tome v., p. 735. 



PROGRESSIVE LOCOMOTOR ATAXIA. 587 

Many special instances might be brought forward, and several 
have occurred in my own practice. The case of Alexandrine Labrosse, 
reported by Combette, 1 is, however, worth referring to more specific- 
ally. His paper is entitled, " Case of a young girl who died in her 
eleventh year, in whom there was complete absence of the cerebellum, 
of the posterior peduncles, and of the annular protuberance." Magen- 
die examined the brain after her death, and satisfied himself that the 
defect was congenital. As M. Combette remarks in regard to this 
case, Alexandrine Labrosse had been able to walk for several years, 
but always in an uncertain manner. Gradually her legs lost their 
strength, and she became paraplegic. She preserved the use of her 
upper extremities to the last. It is very evident, therefore, that the 
weakness of her legs was due to paralysis ; for, had it been the result 
of incoordination, the arms must necessarily have participated. 

For these reasons, I think, it cannot be considered, with any degree 
of probability, that the cerebellum has anything whatever to do with 
the symptoms manifested in sclerosis of the posterior root-zones of the 
cord. Neither is it, in my opinion, necessary to assume the existence 
of an organ whose office it is to exercise a coordinating power. 

The incoordination which is so prominent a phenomenon of scle- 
rosis of the posterior columns is unquestionably due to the loss of 
what is called the muscular sense. 

Sir Charles Bell 2 has argued strongly in support of the existence 
of such a sense. He enunciates his theory in the following sentence : 
" Between the brain and the muscles there is a circle of nerves ; one 
nerve conveys the influence from the brain to the muscle, another 
gives the sense of the condition of the muscle to the brain." 

It is by this connection that we are enabled, according to Sir 
Charles Bell and other physiologists, to form an idea of the state of 
contraction of a muscle, and to lessen or increase the contraction as 
may be necessary. In locomotor ataxia the patient loses this muscu- 
lar sense, or is unable to exert it, for the reason that the posterior 
median columns in lower levels of the cord, and the median portion 
of the posterior external columns at a higher level, through which the 
muscular sense-perception reaches the brain, are by disease rendered 
incapable of transmitting it. 

Before proceeding to the further discussion of this subject, clear 
ideas should be entertained relative to the anatomy and physiology of 
the spinal cord. 

In Fig. 78, which represents a transverse section through the spi- 

1 Jovrnal de physiologie experimeniale et patholoc/ique, par F. Magendie, tome xi.$ 
Paris, 1831, p. 27. 

2 " On the Nervous Circle which connects the Voluntary Muscles with the Brain," 
Philosophical Transactions. Also, " The Nervous System of the Human Body," London, 
1830, p. 225. 



588 



DISEASES OF THE SPINAL CORD. 



nal cord, the posterior nerve-fibres are seen to enter the posterior horn 
of gray matter and the posterior external column. Some of these 
fibres (1 and 2) connect directly with the sensory cells in the posterior 
horn. These fibres probably conduct sensory impressions of pain, 
temperature, and touch. Others (4) terminate in Clark's columns, 

whence the 
fibres spring 
w T hich form 
the direct cer- 
ebellar tract. 
Others, again 
(3), which en- 
ter the poste- 
rior external 
column, aft- 
er ascending 
or descending 
for a short 
distance, en- 
ter the pos- 
terior medi- 
an column 
and ascend to 
the medulla. 
It is through 

this tract that muscular sense is conducted. Some (5), which enter 
the posterior external column, pass directly over to the motor cells on 
the same side. These fibres undoubtedly transmit the deep reflexes. 
The superficial reflexes reach the cells in the anterior horn through 
the posterior horn (7). 

In Fig. 79, which represents a longitudinal section of the cord, 
the course of the nerve-fibres within the cord is clearly demonstrated. 
Such being the connection of the posterior nerve-roots with the 
postericr division of the cord, it is evident that no part of the length 
of these columns can be damaged, either by injury or disease, without 
involving destruction of a corresponding number of nerve-roots, and, 
as these fibres transmit all sensory impressions, their functions must 
necessarily be interfered with ; hence the sharp shooting pains from 
irritation of the sensory roots ; the anesthesia from destruction of the 
nerve-fibres ; the inability to stand with the eyes closed, on account of 
the anaesthesia of the plantar surface of the feet and from the loss of 
the muscular sense ; and the ataxic gait, which is likewise due to the 
impairment of the muscular sense ; and, since reflex action depends 
upon the preservation of the continuity of the reflex arc, the loss of 
the knee-jerk and of other deep reflexes is readily explained. 




Diagrammatic representation of the nerve-fibres entering the cord 
(Modified from Edinger.) 



PROGRESSIVE LOCOMOTOR ATAXIA. 



589 



In sclerosis of the posterior root-zones of the spinal cord the lesion 
generally involves the posterior nerve-roots, the posterior white sub- 
stance, and the posterior cornua of gray substance. Hence the cord 
loses the ability to transmit nervous force. Those unconscious acts 



Fig. 79. 




■\Jbsf: 

MxT.tit 



M 





Diagrammatic representation of the course of the nerve-fibres in the spinal cord. (Edinger.) 

of muscular coordination which are regulated by the gray substance 
of the spinal cord can no longer be perfectly accomplished, and the 
brain is brought to assist in the determination through the sense of 
sight. The patient cannot stand well with his eyes shut, or walk in 
the dark, or determine differences of weight, because he is relying 
altogether on the perceptive faculty of the brain, and this organ is 
not in a condition to perform its work with precision, because sensory 



590 DISEASES OF THE SPINAL CORD. 

impressions do not reach it on account of the destruction of the sen- 
sory pathway in the spinal cord. 

An interesting point connected with the pathology of locomotor 
ataxia is the fact that the spinal lesions sometimes exist in conjunc- 
tion with the cerebral lesions which are the anatomical basis of general 
paralysis of the insane. This subject was alluded to when the last- 
named disease was under consideration. Westphal, 1 who was the first 
to give special attention to this matter, does not believe that there is 
any direct relation between the morbid process in the cord and that in 
the brain. Neither of them is, in his opinion, secondary to the other. 
They simply coexist as the expression of an excessive proclivity to dis- 
ease of the nervous system, just as any other two diseases may be pres- 
ent, one in the brain and the other in the cord, without there being any 
direct interdependence between them. This is undoubtedly correct. 
Locomotor ataxia is by no means uncommon in patients affected with 
the other forms of insanity. Several such cases have come under my 
own observation, and Dr. Patrick Nicol, 2 in an excellent memoir, has 
adduced several instances which have occurred in his experience. 

As we have seen, the lesions in sclerosis of the posterior root-zones 
are not always confined to the original seat. Among other parts of the 
cord liable to be involved is the anterior tract of gray matter. Hence 
we have the more complete development of paralysis and the superven- 
tion of atrophy in the affected muscles. A remarkable instance of loco- 
motor ataxia combined with muscular atrophy formed the subject of a 
clinical lecture, 3 which I delivered at the Bellevue Hospital Medical 
College, in the winter of 1871-'72. In this case there were electric-like 
pains, incoordination, ocular troubles, ptosis, double vision, plantar an- 
aesthesia, etc. After about two years muscular atrophy set in, begin- 
ning in the left leg, then involving the right corresponding member, 
then the left arm, and finally the right upper extremity. 

In this case the lesion of the posterior root-zones was the primary 
lesion, the anterior tract of gray matter subsequently becoming sym- 
metrically implicated. There were no contractions like those present 
when the lateral columns of the cord are the seat of disease. 

In the case of the woman Moli, reported by Pierret,* to which ref er- 

1 " Ueber den gegenwartigen Standpunktder Kentnisse von der allgemeinen progressiveD 
Paralyse der Irren," Griesinger's Archiv fur Psychiatric und Kervenkrankhciten, Heft 
i., Band i., 1867. 

2 ' l On Progressive Locomotor Ataxy and some other Forms of Locomotor Deficiency, as 
found in the Insane," " West Riding Lunatic Asylum Medical Reports," vol. i., 1871, p. 
178. 

3 a Clinical Lectures on Diseases of the Nervous System," New York, 1874, p. 
156. 

4 " Sur les alterations de la substance grise de la moelle epiniere dans l'ataxie locomo- 
trice considerees dans leurs rapports avec Tatrophie musculaire," Archives de physiologic, 
1870, p. 590. 



PROGRESSIVE LOCOMOTOR ATAXIA. 



591 



ence has already been made, there were also the combination of the 
symptoms due to the lesion of the posterior root-zones, and those re- 
sulting from the extension of the morbid process to the anterior horns 
of gray matter — the right side being the seat of profound musculai 
atrophy. On post-mortem examination it was found that the right an- 
terior horn of gray matter in the dorsal and cervical regions was the 
seat of degenerative changes in the nerve-cells, many of which had dis- 
appeared. The horn was markedly diminished in size. These changes 
are shown in the accompanying figure (Fig. 80) from Pierret — a, the 
posterior roots ; 5, the internal radicles, the sclerosis being limited to 
their area ; c, the right anterior horn of gray matter atrophied. This 
association of muscular atrophy with sclerosis of the posterior root- 
zones is to be explained by the fact, first pointed out by Kolliker, 1 that 
some of the internal fibres of the posterior roots pass toward the ante- 
rior horns of gray matter, and can be traced as far as the large cells 
forming the external group. The connection of the fibres of the pos- 
terior roots with the anterior horns of gray matter is also referred to 
by Lockhart Clarke 2 and Gerlach. 3 




TreatniBnt. — It must be remembered that locomotor ataxia often 
spontaneously remits in the violence of its symptoms. Indeed, the re- 
mission may at times amount to almost a complete intermission. But 
taking this fact into full consideration, I am quite sure that the disease 
is not in every case uninfluenced by medical treatment. A great many 
medicines have been recommended, and numbers of cures have been re- 
ported. Careful inquiry, however, suffices to show either that the al- 



1 "A Manual of Human Histology," "Sydenham Society Translations," vol. i., 1853, 
p. 415. 

2 "Philosophical Transactions," 1853. 

3 Strieker's "Manual of Histology," American edition, New York, 1872, p. 645. 



592 DISEASES OF THE SPINAL CORD. 

leged cures were merely instances of more or less complete remission, 
or that the cases were really not examples of the disease in question. 
To even mention the assumed remedies would be profitless labor. 

In the very earliest period of the disease ergot is calculated in some 
cases to be of decided benefit. It should be administered in doses of 
at least a drachm three or four times a day, and continued for several 
months. The bromide of potassium, sodium, or calcium, is an effica- 
cious adjuvant. Under the combined use of these remedies I have 
repeatedly seen the electric-like pains diminish in violence or even 
altogether disappear. The gastric disturbances may often be allevi- 
ated by bismuth, or, what is usually still more efficacious, by Fair- 
child's pepsin in doses of three or four grains with each meal. 

With these measures the primary galvanic current applied to the 
spine, on each side of the spinous processes, is an agent which ought 
to be used. Cases have been reported by Meyer, Benedict, and others, 
in which it alone has apparently effected cures — or arrest of the mor- 
bid process — and Rosenthal 1 speaks highly of its beneficial influence. 
I have used it with success in several cases in conjunction with the 
means previously mentioned. Ordinarily, it has not appeared to me 
to be of any material service. 

The pains in the back and the sharp shooting pains in the legs or 
arms and around the abdominal and thoracic regions may be com- 
bated with phenacetine in ten- or twelve-grain doses, or antifebrine in 
five-grain doses, either of which can be repeated in an hour if neces- 
sary, or by codeine in doses of from half a grain to one or even two 
grains, or with hypodermic injections of morphia. 

If the case comes under observation when the motorial troubles are 
well marked, or if, after having used it for a month, no decidedly 
beneficial effect follows the treatment just specified, I omit the ergot, 
and frequently use instead, the nitrate of silver in doses of the quarter 
of a grain three times a day. According to Rosenthal, 2 Wunderlich, 
Charcot and Yulpian, Herschell, Klinger, Duguet and Vidal, have ex- 
tolled its merits. This remedy has in my hands apparently proved ser- 
viceable in several cases which were well advanced, but I am not able 
to speak definitely on the subject, for the reason that with it bromide 
of potassium, and especially galvanism, were used. Two cases were 
cured by the combined remedies — one of them was that of a distin- 
guished journalist, who, in the first place, was treated with ergot, and 
subsequently, when this medicine appeared to be of no further effect, 
with the nitrate of silver. At the present time, seven years having 
elapsed, this gentleman is well, free from pains, able to coordinate, 
and with no symptom of the affection remaining. The disease was first 
manifested by an epileptic paroxysm, and soon afterward ocular trou- 
bles made their appearance. The electric-like pains, abdominal con- 

1 " Klinik der Nervenkrankheiten," Stuttgart, 1875, p. 394. 2 Op. eft., p. 390. 



PROGRESSIVE LOCOMOTOR ATAXIA. 593 

striction, and incoordination in the upper and lower extremities, were 
well marked. He was under treatment for about four months. The 
other case was that of a lady of this city. The disease in her began 
with pain in the back, and electric pains in the lower extremities 
Ptosis, dilatation of the right pupil, and diplopia followed, and then 
gradual loss of sensibility in the soles of the feet, and difficulty in coor- 
dinating the muscles of the legs. The disease had lasted two years and 
a half when the patient came under my charge. She was treated with 
the nitrate of silver and the other remedies mentioned, for nearly a 
year, and throughout the whole period gradually improved till her 
recovery was complete. The nitrate of silver was suspended for a week 
after each month of its administration. 

In a third case ergot and nitrate of silver were given together with- 
out the bromide of potassium. This case was that of a gentleman, a 
merchant of this city, residing in Bridgeport, Connecticut. He had had 
ocular troubles, and was suffering from pains, incoordination, plantar 
anaesthesia, paralysis of the bladder, and swelling of the right knee, 
when he came under my charge, being sent to me by my friend Dr. 
Hubbard, of Bridgeport. The disease had then lasted only a few 
months. With the medicines, the constant galvanic current to the 
spine and spinal nerves was employed. He was entirely cured in less 
than three months. 

In all cases inquiry should be made with reference to the existence 
of a syphilitic taint. If affirmative results follow the investigation, the 
iodide of potassium should be administered in gradually-increasing doses 
as recommended for acute spinal meningitis, or in combination with 
corrosive sublimate, according to the formula given on page 308, recol- 
lecting that galvanism is likewise to be used, and such other treatment 
as the special symptoms may seem to require. Two cases were cured 
by this treatment; one of them was that of a gentleman from the West 
— a fully-developed case — who had been treated by my friend Dr. 
Bumstead, for other syphilitic troubles, and who sent him to me for his 
spinal disease. The incoordination, plantar anaesthesia, pain in the 
lumbar region, and the electric pains, were all present, together with 
slight diplopia. He was under treatment for about ten months. I met 
him a few weeks since in a railway-car, the picture of health, and, as he 
told me, perfectly well. 

The other case occurred in the person of a gentleman of this city, 
and was similar in general features to the preceding. A cure was ob- 
tained, after like medication, in six months. 

In the majority of cases, whether there is a syphilitic taint or not, 
I administer the iodide of potassium. Beginning with moderate 
doses, it should be gradually increased up to the point of toleration, 
which differs vastly in different individuals. The iodide of potassium 
is very efficacious in preventing the formation of new connective tis- 



594 DISEASES OF THE SPINAL CORD. 

sue. In this manner, I am convinced, the progress of the disease is 
often arrested, and in the early stage, which is probably one of simple 
congestion only, destruction of the nerve-fibres may be avoided. 

In another case, after ergot had been used for several months with- 
out apparent benefit, the nitrate of silver was administered with the 
effect, to all appearance, of checking the further progress of the disease, 
and producing decided amelioration of the existing symptoms. The 
patient, a distinguished member of the dramatic profession, by my ad- 
vice withdrew from the stage, and, being in Philadelphia, he consulted 
at my suggestion Dr. Weir Mitchell, who unhesitatingly confirmed my 
diagnosis. He took the nitrate persistently for about six months, and 
was so greatly improved that I gave my consent to his resuming his 
profession. There are now no pains; his coordination is good, and his 
general health leaves nothing to be desired. 

In several cases I have obtained ameliorations by the use of phos- 
phoric acid, phosphorus, and chloride of barium, but after extensive 
experience with these agents, I am unable to report any permanently 
good results. 

If the vesical sphincter be paralyzed, belladonna may be used with 
advantage, preferably in the form of hypodermic injections of atropia 
gradually increased daily, from the one hundred and twentieth of a 
grain to the thirtieth. 

Hydro-therapeutics in all forms, and faradization, have never, ac- 
cording to my experience, been of the slightest benefit, except as re- 
gards the use of the latter to the affected muscles. The ether-spray 
recommended by Jaccoud has been entirely inefficacious in my hands, 
and the same may be said of all plasters and embrocations. 

One auxiliary means of treatment I have lately employed with ad- 
vantage, and that is, keeping the patient as much as possible from 
using the groups of muscles which have lost their coordinating power, 
and requiring him, when he walks, to employ crutches to assist him, 
By systematically carrying out this plan the nervous force of the pa- 
tient is not wasted, and a diseased organ, such as is his spinal cord, is 
not overtasked. 

Lately I have employed, and thus far with apparently good re- 
sults, the actual cautery to the spinal column. I have used it in a 
great number of cases. The effect has been to lessen, and in many 
cases entirely to abolish, the electric pains and the feeling of con- 
striction around the body. In one fully-developed case which I 
had before the medical class of the University of New York, the 
pains, which were of great intensity, ceased within a few hours after 
the first cauterization. Ten days subsequently I repeated the oper- 
ation, the pains in the legs having returned, and again the relief was 
complete. 

Nerve-stretching is a therapeutical measure of some importance. 



PROGRESSIVE LOCOMOTOR ATAXIA. 595 

Langenbeck 1 was the first to perform this operation for locomotor 
ataxia, and the results, not only in relieving the electric-like pains for 
which the operation was performed, but in curing the ataxia, were 
such as to astonish the operator. For a short time afterward the 
reports of cases cured by this means were numerous. Certainly noth- 
ing in the whole range of neuro-therapy is so contrary to our precon- 
ceived opinions as to suppose for one instaut that stretching the sci- 
atic nerves will have any influence in restoring sclerosed nerve-tissue 
to a normal condition. In time nerve-stretching was relegated to its 
proper place as a therapeutic measure. Sometimes the pains in the 
affected limbs are so severe that the ordinary forms of treatment are 
not adequate for their relief, and the patient gradually becomes ex- 
hausted from suffering and from loss of sleep. In such a case stretch- 
ing the sciatic nerves invariably puts an end to the suffering, some- 
times for several weeks and again for several months, and when the 
pain does return it is frequently of a more subdued character. The 
operation is simple, and free from danger. An incision should be 
made in the mesial line of the integument on the posterior surface of 
the thigh just above the popliteal space. On separating the biceps 
from the semitendinosus, the sciatic nerve will be readily discovered,, 
If the little finger is then passed under the nerve, the latter can be 
stretched to the desired extent. 

The treatment of ataxia by suspension has recently attracted con- 
siderable attention. It was first practiced by Dr. Motchoukowski, of 
Odessa, Russia, as far back as 1883, but attracted no attention from 
the medical profession until Charcot 2 published his article attesting 
to its efficiency as a therapeutic agent. Since then numerous cases of 
ataxia have been reported to have been cured by this means ; but, 
though my experience with this method of treatment has been exten- 
sive, I cannot say that I have ever seen a single case of genuine tabes 
in which suspension alone has arrested the progress of the disease. 
That it is of material assistance in relieving some of the symptoms of 
tabes in the majority of cases is beyond the shadow of a doubt ; but 
it has also been shown that in a small proportion of cases the symp- 
toms are aggravated with each successive suspension. 

The modifications most liable to occur from suspension are : an 
improvement in the coordinating powers, thereby enabling the patient 
to stand and to walk better ; an amelioration in the sharp, shooting 
pains in the affected extremities ; and an abatement of the gastric 
crises. The difficulty of retaining or of passing the urine often ceases, 
and the sexual power, which is frequently weakened, is sometimes 
restored. Improvement from suspension is not apparent from the 
first. Usually from ten to fifteen or more suspensions are necessary 
before decided benefit is manifested. 

1 Berlmer klin. Wochenschrift, No. 48, 1879. 2 Le prog, rned., Jan. 19, 1889. 



596 DISEASES OF THE SPINAL CORD. 

The best suspension apparatus, to my mind, is one by which the 
traction is borne by the occiput and chin, the axillary supports not 
being used at all. The apparatus should be hung on a weight scales, 
so that the exact amount of traction exerted can be known and noted. 
The accompanying illustration (Fig. 81), made from a photograph, 

Fig. 81. 



gives an excellent representation of the apparatus as I first used it. 
Since then, however, the interposition of a weight-scales between the 
head-gear and the pulley-ropes, and the abolition of the axillary sup- 
ports, make the instrument much more scientific and exact. At first 
the traction should not exceed seventy-five pounds, and should be 
gradually increased with each suspension, until the limit of one hun- 
dred and twenty or one hundred and thirty pounds is reached. In the 



INFLAMMATION OF THE COLUMNS OF GOLL. 597 

beginning the suspensions should not last longer than half a minute, 
but should be extended gradually up to two minutes. 

Judging from my own experience, and considering the experience 
of others who have used suspension properly, I cannot help being 
satisfied with the results obtained. Beneficial effects are more likely 
to follow in cases of incipient tabes than in those of longer duration, 
in which destruction of the nerve-fibres has taken place to a consider- 
able extent. In three cases of functional impotence decided evidence 
of amelioration was shown after three suspensions. 

Suspension is contra-indicated where tabes coexists with valvular 
cardiac disease, phthisis, and extreme anaemia. 

IX. 

INFLAMMATION SCLEROSIS — OF THE COLUMNS OF GOLL. 

We have seen that the columns of Goll or posterior median fasciculi 
are generally the seat of a lesion simultaneously with, or more probably 
secondarily to, that which, existing in the posterior root-zones, causes 
the group of symptoms we call locomotor ataxia. 

There is, however, no doubt that they may be the seat of primary 
disease, and, though the data are not yet sufficient to enable us to give 
the clinical history of the affection as fully as is desirable, we are not 
altogether without information on the subject. Our definite knowledge 
rests upon one case reported in full by Pierret, 1 and which I quote, 
greatly condensed as follows : 

Catherine Magnaigat, when thirty years of age (1855), experienced 
numbness, " pins and needles," sensations of heat, and deep-seated pains 
in the extremities, especially the upper. There were also pains in the 
loins, obstinate headache, and a sense of tightness around the chest. 

In 1860, vertigo and weakness of the lower extremities super- 
vened. She did not distinctly feel the ground with her feet, and she 
was obliged to walk with a cane. 

In 1863 she entered the Salpetriere, and came under M. Charcot's 
care. Her condition was then as follows : 

Tactile sensibility was diminished in the soles of the feet, the left 
especially. She could not walk without a crutch, which she used under 
her right arm. When she wished to go forward she experienced an 
impulse to spring or leap, and finally she advanced by a series of short 
steps, and felt as if impelled by a force she could not resist. When she 
closed her eyes while standing alone she maintained the erect position 
for a while, but would eventually have fallen unless supported. She 
was easily fatigued, and walking caused pains which compelled her soon 
to stop. Her feet seemed to stick to the ground when she made volun- 

1 "Notes sur un cas de sclerose primitive du faisceau median des cordons posted 
rieurs," Archives de vhysiologie, 18Y3, p. 74. 



598 



DISEASES OF THE SPINAL CORD. 



tary efforts to lift them. Sometimes, when she attempted to advance, 
she felt herself irresistibly drawn toward the left side. AVhen after 
having taken a few steps she wished to go back, she turned round 
suddenly, as if moved by a spring. In 1866 she for the first time ex- 
perienced constricting pains around the body low down, and electric- 
like in character. Soon afterward she felt similar pains in the anterior 
part of the thighs. Cutaneous sensibility was then diminished in the 
lower extremities. The idea of the exact position of the limbs was 
not in the least impaired, and there was no incoordination. Such was 
her condition when in 1871 she died of pneumonia. 

The post-mortem examination showed that the columns of Goll 
were throughout their whole extent in a state of sclerosis. It was 
most manifest in the dorsal region, where it to a slight extent invaded 
the posterior root-zones, to which circumstance, doubtless, the electric- 
like pains experienced by the patient were due. 

The case would appear to show that sclerosis of the columns of 
Goll gives rise to certain symptoms in the lower extremities, however 
much the superior may retain their normal condition. In some cases 
of locomotor ataxia there has been noticed an unusual feeling of 
heaviness in the lower extremities, or a marked tendency to go back- 
ward, or a great feeling of fatigue after 
slight exertion, a marked incertitude in 
standing erect, or even an irresistible feel- 
ing of propulsion. In such instances, there- 
fore, the columns of Goll were affected at 
the same time with the posterior root-zones. 
M. Pierret holds the opinion that these col- 
umns, to some extent, preside over motion. 
Figs. 82, 83, 84, and 85 represent scle- 
rosis limited to the columns of Goll, and 
are taken from M. Pierret's memoir. Fig. 



Fig. 82. 




Fig. 83. 



Fig. 84. 



Fig. 85. 






82 refers to the cervical region, Fig. 83 to the dorsal. Fig. 84 shows 
the appearance of a section made at the level of the second dorsal 
vertebra, and Fig. 85 one taken from the upper part of the lumbar 
enlargement. The sclerosed portion is represented at a in each figure. 



DISSEMINATED INFLAMMATION OF THE SPINAL CORD. 599 

In the present state of our knowledge, all that we can do is to await 
further developments relative to the interesting points raised by the 
case which M. Pierret has so well studied. 

X. 

DISSE^ILSATED LSTLAMilATIOX OF THE SPIXAL CORD MULTIPLE SPINAL 

SCLEROSIS SCLEROSIS IX PLATES INSULAR SCLEROSIS. 

Thus far we have considered the inflammatory affections of the 
spinal cord as they appear in one or another of the anatomical divisions 
which make up that nerve-centre. But we have now to engage our- 
selves with a lesion which has no fixed habitation, which is met with in 
the gray and white matter indiscriminately, and which occurs in distinct 
foci, patches, plates, or islets, in various parts at the same time or con- 
secutively. This is what is known as multiple spinal sclerosis or 
sclerosis in disseminated plates — the sclerose en plaques diss&minees of 
Charcot. 

Symptoms. — Multiple spinal sclerosis generally first manifests its 
presence by more or less weakness in one or the other lower extremity. 
Before long the corresponding limb becomes involved; and, eventually, 
if the disorder continues to form additional centres of morbid action, 
the upper extremities are successively attacked. 

At other times the first symptoms are connected with sensibility, and 
consist of the various sensations of numbness, tingling, "pins and 
needles," formication, and the like. Or these phenomena may make their 
appearance simultaneously with the paresis. The gait of a person 
affected with multiple spinal sclerosis is uncertain and titubating — like 
that of an individual slightly intoxicated. Although there is defective 
coordination, the patient stands as well with the eyes shut as open, and 
has no additional difficulty in walking in the dark or with the eyes 
closed. 

The paralysis advances, but there are no marked disturbances of 
sensibility, and the numbness which may have been present to some 
extent in the early stage usually disappears. The patient is, therefore, 
sensitive to changes of temperature, to pain, and to pressure. Pains 
are very uncommon. Occasionally, there are slight painful sensations 
in the paralyzed parts, but they are temporary. 

The general health usually remains good, and the mind is unaf- 
fected. 

Later, in the course of the disease, rigidity or contraction makes its 
appearance in the paralyzed limbs, or both these conditions may co- 
exist in the same extremity, some of the joints being contracted, and 
others rigidly extended. The tendency is for these conditions to be- 
come permanent. Again, there are violent tonic convulsions in the 
paralyzed limbs which may be spontaneous, but which are readily ex- 



600 DISEASES OF THE SPINAL CORD. 

cited by impressions made upon the skin of the affected extremities, or 
even sometimes by mental emotions. They may precede, or coexist 
with, or follow the permanent contractions. 

In some instances these phenomena are not met with. They were 
absent in the case of Dr. Pennock, reported by Drs. Morris and Mitchell; 
in a case under my own charge, and in which I made an examination of 
the cord soon after death ; and in a case reported by Friedreich, 1 in 
which multiple spinal sclerosis existed in conjunction with the lesions 
of locomotor ataxia. 

When present, as they generally are, these permanant contractions 
of the muscles exhibit different phases in the upper and lower extremi- 
ties. In the former the flexors predominate over the extensors, while in 
the latter the extensors prevail. The spasmodic tonic convulsive move- 
ments of the limbs are especially met with in the lower extremities, the 
upper being rarely their seat. 

After a time, which may vary from three or four to fifteen or twenty 
or even more years, the limbs become almost entirely paralyzed, and 
the contraction and rigidity are still more strongly marked. Whatever 
voluntary movements the patient is capable of executing now cause 
pains in the parts. The sensibility usually, however, even at this period 
remains but little affected. Reflex excitability generally exists though 
perhaps slightly impaired ; sometimes it is altogether lost, and again 
it may be greatly exaggerated. The bladder and the sphincter ani 
retain their power to the last. Bed-sores form on the parts subjected 
to pressure as the patient lies in bed, and death eventually ensues, 
either from exhaustion or from some intercurrent affection. 

Such is a description of multiple spinal sclerosis as it is ordinarily en- 
countered — and it must be confessed that the clinical features are not 
very striking or peculiar. But even this type, imperfect as it is, is sub- 
ject to great diversities. Sometimes there are violent pains of an elec- 
tric-like character simulating those which are so prominent a feature of 
locomotor ataxia and like them resulting from the implication of the 
posterior root-zones in the lesion. Sometimes the superior extremities 
are attacked first. Again, anaesthesia constitutes, a prominent feature, 
and the phenomena ordinarily present may be more or less modified in 
extent and intensity in different cases. 

In their very excellent monograph on the subject, MM. Bourneville 
and Guerard, 2 in detailing the symptomatology of the spinal form of 
disseminated sclerosis, say: 

" After a variable time the superior and inferior extremities become 
tne seat of rhythmical agitations, which are only present, however, 

1 "Ueber degenerative Atropine der spinalen Hinterstrange," Archiv fur pathologischt 
Anatornie und Physiologie, 1863, p. 433. 

8 "De la sclerose en plaques disseminces," Paris, 1869, p. 61. 



DISSEMINATED INFLAMMATION OF THE SPINAL CORD. 601 

when spontaneous or voluntary movements are made. In the state of 
repose the members are not affected with any tremor." 

In this connection I desire to repeat what I wrote five years ago, J 
that " tremor is never observed in spinal sclerosis of any form, diffused, 
multiple, or cortical, unless the pons Varolii or superior ganglia of the 
brain are implicated. In the only case of this latter form published — 
that of Vulpian 2 — the sclerosis extended throughout the whole length 
of the cord, and likewise involved the pons Varolii, cerebellar peduncles, 
and other intra-cranial organs, besides being accompanied with well- 
marked spinal meningitis. The tremor observed at a late period of the 
disease cannot, therefore, be ascribed to the lesion of the cord below the 
medulla oblongata." 

Of the cases cited by Bourneville and Guerard in which post-mortem 
examinations were made, one from Vulpian and one from Morris and 
Mitchell, in which the lesions were restricted to the cord, there was no 
tremor at any time in the course of the disease; and in a case of my own 
already cited, and which will be still more specifically referred to here- 
after, in which the cord was the seat of several islets of sclerosed tissue, 
tremor had never been a feature of the symptomatology. 

As we shall see hereafter, when we come to the consideration of the 
cerebro-spinal form of the disease — multiple cerebro-spinal sclerosis — 
tremor constitutes one of the most prominent phenomena of the affec- 
tion. We have already seen that it is a marked symptom of the purely 
cerebral type of the affection. I am quite sure, however, that in the 
disease we are now considering, restricted as its lesions are to the 
spinal cord, rhythmical tremor is not encountered. 

Causes. — The causes of multiple spinal sclerosis are not well under- 
stood. In a case fully reported by Vulpian, 3 the affection appeared to 
have been induced by a sprain of the left ankle. The extremity re- 
mained weak, and three years afterward the patient had a fall, and 
then the right lower extremity became weak and subsequently the 
right upper extremity. The left upper extremity was not affected 
for several 'years. 

In the case of Dr. Pennock, reported by Drs. Morris and Mitchell, 
the disease began while the patient was busily engaged in professional 
studies. 

In the case in which I verified the existence of the disease by post- 
mortem examination, it was apparently caused by exposure to cold and 
dampness. 

It is probable that blows on the spine, concussions — such as are pro- 
duced by railway accidents — and the gouty and syphilitic diatheses — 

1 First and subsequent editions of this work, p. 473. 
8 Op. cit., p. 64, et seq. 

3 "Note sur la sclerose en plaques de la moelle epiniere," Union medicate, 1866, Juin 
?, 9, 14, et 19, obs. i. 



602 DISEASES OF THE SPINAL CORD. 

may induce multiple spinal sclerosis. There is in reality no reason, to 
my mind, why all the influences which are capable of causing the dif- 
fused forms of sclerosis which have been considered, may not also 
cause the disseminated variety. But it is difficult to arrive at any 
definite information relative to this matter, so long as the clinical 
features of the disease are so little characteristic. 

Diagnosis. — There is very little in multiple spinal sclerosis sufficient- 
ly pathognomonic to aid us in our diagnosis of the affection. The 
symptoms in some cases are identical with those of spastic spinal paral- 
ysis ; in others they resemble those of locomotor ataxia, as in the two 
cases reported by Friedreich, to one of which allusion has already been 
made. In the present state of our knowledge, therefore, I am afraid 
we must wait for the scalpel and the microscope to determine with any 
degree of accuracy the diagnosis of multiple spinal sclerosis. 

Prognosis. — The disease is not one which is directly calculated to 
cause death. All the patients known to have died while subject to it, 
succumbed to some intercurrent affection, such as bronchitis, dysentery, 
typhoid fever, and pneumonia. It undoubtedly tends to weaken the 
vital powers, and hence is indirectly the cause of a fatal result. So far 
as any prospect of arresting, by therapeutic means, the tendency to the 
formation of other islets of inflammation and sclerosis, or of restoring 
the integrity of the cord is concerned, there does not appear to be much 
hope. For, though its progress is in many cases slow, and in others 
seems, at times, to be self -limited, it pursues its course unamenable, so 
far as we know, to medical treatment. In the diffused forms of spinal 
sclerosis there is but one centre of morbid action ; in the disseminated 
there are several, which, if not coexistent, tend, through an inherent 
proclivity, to be produced indefinitely. To this circumstance is due the 
fact that the prognosis of the disease under consideration is more un- 
favorable than that of sclerosis of the posterior root-zones or even sym- 
metrical lateral sclerosis. 

Morbid Anatomy and Pathology. — Multiple spinal sclerosis consists 

in the dissemination through the cord of masses of sclerosed tissue, 
which have resulted from the proliferation of the neuroglia and the 
consequent atrophy and disappearance of the projDer nerve-elements. 
They are of a gray color, of increased consistence, of irregular size and 
form, and may exist in any part of either the gray or white tissue of 
the cord ; often, however, manifesting a tendency to involve the two 
lateral halves of the cord symmetrically. 

In the case reported by Vulpian, the volume of the cord was evi- 
dently diminished, and on different points of its surface exhibited an 
ashy-gray coloration. The antero-posterior diameter of the cord was 
markedly lessened at those places where the islets of sclerosed tissue 
existed. 

In this case there had been progressive paresis, rigidity, and con 



DISSEMINATED INFLAMMATION OF THE SPINAL CORD. 603 

traction, with extension of all four limbs, without tremor of any kind. 
The alterations were found in the anterior, lateral, and posterior col- 
umns, and in the anterior and posterior horns of gray matter. 

In the case of Dr. Pennock, reported by Drs. Morris and S. Weir 
Mitchell, 1 the sclerosed tissue was confined mainly to the lateral col- 
umns. The posterior were involved to a very small extent. In this 
case there were partial anaesthesia, gradually-advancing paralysis im- 
plicating all four extremities, and paralysis of the bladder. The intel- 
lectual faculties were never affected in the least. The course of the 
disease was progressively onward, and, though there was toward the 
last a total loss of voluntary power below the neck, reflex action re- 
mained unaffected. There were no tremors with or without voluntary 
movements. In regard to this case, Dr. Mitchell, who made the micro- 
scopical examination, remarks that there were : 

" 1. Integrity of mental and moral manifestations. 

"2. Absolute loss of voluntary motive power below the head, or 
rather below the neck. 

" 3. Sensation nearly perfect. 

" 4. Respiration good ; reflex motion preserved and exhibited in the 
form of spasm or irritation of certain parts of the skin." 

All of which are what we should expect to find in sclerosis almost 
entirely confined to the lateral pyramidal tract. 

In the case which I have mentioned as coming under my own obser- 
vation, the patient, J. H., consulted me in the winter of 1869-'70. He 
was then unable to walk without a cane and the assistance of an attend- 
ant. He had previously been treated at a water-cure establishment, 
and more recently by the Swedish movement-cure, and of course with- 
out benefit. The symptoms were mainly connected with motility. 
Both lower extremities were paralyzed ; the bladder was inactive, but 
not the sphincter, and there was obstinate constipation. There were 
occasional fibrillary contractions of the paralyzed muscles, and at times 
pain in the back and limbs — never, however, of any great degree of 
severity. There were no tremors, either with or without voluntary 
motions. 

The patient obtained very little benefit from the treatment to which 
I subjected him, and I advised him to return to his home in Ohio. A 
few months afterward, he died. 

The dorsal, lumbar, and sacral regions of the cord were sent to me 
for examination by his physicians, Drs. Ramsey and Bishop, of Delhi, 
Ohio. In a letter, the latter informed me that the vessels of the pia 
mater were injected. 

The cord arrived in good condition, having been carefully preserved 
in strong alcohol. Upon inspection, the antero-lateral columns in the 

1 American Journal of the Medical Sciences, July, 1868. 



604 DISEASES OF THE SPINAL CORD. 

middle and lower dorsal regions to the extent of three and a half 
inches were seen to be of a grayish tint, which became deeper in shade 
from above downward. Below this, at the junction of 'the dorsal with 
the lumbar portion, was another patch two and a half inches in length, 
and also involving the whole superficies of the antero-lateral columns ; 
and, separated from this by a portion of apparently healthy tissue, was 
another discolored, irregular patch, an inch and a half in length, along 
the left antero-lateral column ; and, below this, a similar tract, two 
inches and an eighth long, involving the right antero-lateral column. 
The difference in consistence between these patches and the other parts 
of the cord was very decided, and the white striae were well marked. 
The sacral portion of the cord presented no abnormal appearance to 
the naked eye. 

Sections of the cord were then made through the sclerosed portions; 
and it was seen that the gray matter was only involved where the 
horns approached the surface ; and that, wherever a lesion existed, 
the normal contour of the sections was altered so as to make them sub- 
ovoidal, and thus to lessen the circumference. The greatest depth of 
any part of a sclerosed region was two-twelfths of an inch, and this 
was in the superior patch. The average thickness was about the one- 
twelfth of an inch. 

The whole cord in my possession was then immersed in a solution of 
chromic acid in water, and left there for a month to harden. Immedi- 
ately previous to examining with the microscope, the sections were col- 
ored by an ammoniacal solution of carmine. Under a twelfth-inch ob- 
jective, it was seen that, throughout the whole extent of the sclerosed 
portion of any section, the nerve-tubes had entirely disappeared ; and, 
wherever the gray substance was affected, the nerve-cells were dimin- 
ished in number. In the place of these elements were connective tis- 
sue, a large quantity of molecules, and connective-tissue cells in great 
abundance. 

In several sections taken from the dorsal, lumbar, and sacral re- 
gions, and which were apparently normal when viewed with the naked 
eye, the neuroglia was found to be in excess, and the nerve-tubes in a 
state of disintegration. 

The gray matter, except in those sections made through the part 
where the sclerosed portion extended from the white matter to it, was 
uniformly healthy, and in no part were the posterior columns in- 
volved. 

In this case there was no tremor, although it was clearly one of 
multiple sclerosis, probably entirely confined to the spinal cord. At no 
time had there been head-symptoms of any kind. Histologically, 
therefore, we see that the sclerosed tissue consists mainly of an exces- 
sive amount of connective tissue — the neuroglia of Virchow. The cells 
are increased in size, and the nuclei are larger and much more numerous 



SECONDARY INFLAMMATION AND DEGENERATION. 605 

than in the normal condition. The capillaries are thickened, from the 
deposition on their walls of several layers of rounded cells. 

The effect of this morbid process is to compress the nervous fila- 
ments and to cause their atrophy. The fluid portion undergoes fatty 
degeneration, and the axis cylinders become disintegrated. Still, how- 
ever, they present somewhat of their characteristic color and consist- 
ency, and appear as white striae traversing the morbid tissue. 

The membranes often exhibit evidences of inflammation, and are 
thickened, opaque in spots, or red in some cases, while in others they 
are adherent to each other and to the cord. 

Treatment. — Something can be done to mitigate the violence of the 
symptoms. Hypodermic injections of atropia have often a happy effect 
in diminishing the force and frequency of the tonic contractions. The 
nitrate of silver has been used by M. Piorry with temporary good re- 
sults. 

The primary or galvanic current has, in my hands, been of like effi- 
cacy in lessening the contractions or spasmodic rigidity, but with this 
agent, as well as with the others mentioned, there can be no great cer- 
tainty that we are dealing with a case of multiple spinal sclerosis. We 
are, therefore, forced to treat symptoms instead of lesions. 

Still, for the cure of the disease we may attempt the measures 
recommended for symmetrical lateral sclerosis, but with even less 
prospect of success. I should be disposed to use, with thoroughness 
and persistency, the actual cautery in the manner recommended when 
discussing the treatment of locomotor ataxia. 



XI. 

SECOXDAEY INFLAMMATION ASD DEGENEEATION OF THE SPIXAL COED. 

It is a well-recognized fact that disuse of an organ promotes its 
atrophy and degeneration. A muscle, which from any cause is ren- 
dered incapable of contracting, becomes smaller, and its fibrillar under- 
go conversion into fat. The same law applies to other organs, and 
among them the spinal cord. Whatever interrupts the passage of the 
normal excitations through its columns causes degeneration. Thus, if 
there be a cerebral haemorrhage, preventing the action of the brain on 
the muscles, the lateral pyramidal tract on the opposite side and the 
anterior pyramidal tract on the same side of the cord, not being stim- 
ulated by their accustomed excitation, undergo the change mentioned. 
If the cord itself be the seat of a lesion, or the posterior nerve-root c , 
and perhaps even the nerves or muscles, the posterior columns above, 
no longer being required to convey impressions to the brain, suffer 
atrophy and degeneration. To this alteration, which is not itself a 
primary disease, but which is always, in its very nature, consecutive 



606 DISEASES OF THE SPINAL CORD. 

to lesions in superior or inferior parts of the nervous system, the term 
secondary degeneration has been applied. 

The fact that the spinal cord is affected by lesions of the 
brain was observed by Cruveilhier, 1 who, however, failed to notice 
any consecutive change in the cord below the decussation of the 
pyramids. 

L. Tiirck 2 was the first specially to inquire into this important 
subject, and, in a series of memoirs extending through the years from 
1851 to 1855, he showed that the cord underwent secondary degener- 
tion, both from lesions of the brain and of its own substance. Since 
these memoirs, other pathologists, among whom MM. Charcot, Turner, 
Rokitansky, Vulpian, Cornil, and Lancereaux, may be mentioned, re- 
ported cases, but no one has investigated the subject with so much 
thoroughness as M. Bouchard. 3 

Symptoms. — The most important symptoms referable to second- 
ary degeneration of the cord from cerebral lesions are muscular con- 
tractions, exaggerated tendon reflexes, and the ankle clonus. These 
are not the contractions which sometimes exist from the very in- 
ception of a haemorrhage, for instance, but those which come on at a 
later period of the disease, and which, like the first, have generally been 
thought the consequence of irritation existing about the cicatrix. Bou- 
chard, however, shows very clearly that they are the result of secondary 
changes taking place in the spinal cord, and the clinical history of which 
has not hitherto been carefully studied. They are very frequent. Of 
thirty-two cases of old hemiplegia analyzed by Bouchard, they were 
present in all but one. From my own experience I think it is safe to 
say that it is very rare to meet with a case of hemiplegia of over a 
year's duration in which they do not exist. 

In examining a patient suffering from an old hemiplegia, it is com- 
mon to find the forearm of the paralyzed side flexed on the arm. Fre- 
quently, also, the fingers are bent into the palm of the hand, the hand 
flexed on the forearm, and the whole member carried across the front 
of the body, and held firmly against it by the contraction of the pecto- 
ralis major muscle. In such a case we find the muscles atrophied, hard, 
and stretched to an extreme degree of tension. Rectification of the 
position is, to a great extent, impossible by the voluntary efforts of the 
patient. He may be able to accomplish a little motion, and to do still 
more by using the sound hand to extend the affected arm ; but, if the 
hemiplegia has been of considerable duration, the range of his motility,, 
with or without assistance, is very small, and is sometimes nothing. I 

1 "Anatomie Pathologique," liv. xxxii., p. 15. 

2 " Ueber secondare Erkrankung einzelner Kuckenmarksstrange und ihrer Forsetzun- 
gen zum Gehirne," " Sitzungsberichte der Kaiserlichen Wiener Academie," 1851. 

* u Dea degenerations secondaires de la moelle epiniere," Archives generates di 
mid., 1866. 



SECONDARY INFLAMMATION AND DEGENERATION. 



607 



have found that the electric contractility of such muscles is diminished 
in some of their fibres, unaffected in others, and exalted in others, so 
that, when the electrical stimulus is applied, a hard, irregular, and 
knotty contraction is obtained. Polar degenerative reactions are not 
observed. 

The leg is usually stiff, and flexion of the knee-joint is performed 
with difficulty. The foot is generally flexed till it is brought into a 
position of talipes equinus. This gives a marked peculiarity to the 
gait. The flexion of the foot prevents the toes from being drawn 
upward when the leg is thrown forward, as in the act of walking. 
This, in addition to the rigidity of the knee-joint, makes it necessary 
for the leg to be thrown outward from the body while the foot de- 
scribes the arc of a circle. 

This condition of contracture only affects those muscles which 
have previously been paralyzed. 

The knee-jerk, and the tendon reflexes generally, are exaggerated, 



Fig. 86. 




/J7/IC. 

Diagrammatic representation of the connections of the motor nerve-cells of the anterior 
horn. (Modified from Brum well.) 

Ipt, Lateral pyramidal tract, apt, Anterior pyramidal tract, or column of Turck. 
pmc, Posterior' median column, or column of Goll. pec, Posterior external column, 
or column of Burdach. dte, Direct cerebellar tract, a-l at, Antero-lateral ascend- 
ing tract, or column of Gowers. M, a muscle. B, a deep reflex fibre passing through 
the posterior external column and joining the motor nerve-cell at 3. S, superficial 
reflex fibre passing through the posterior horn of gray matter and joining the motor 
cell at 2. 1, Fibre connecting the lateral pyramidal tract with a motor cell. 4, Moto;- 
nerve-fibre from motor cell to muscle. 5, Motor nerve-fibre from the anterior pyram- 
idal tract to motor nerve-cell. 

and the ankle clonus can readily be obtained. In fact, the symptoms 
are nearly identical with those described under the heading of Pri- 



608 DISEASES OF THE SPINAL CORD. 

mary Sclerosis of the Lateral Pyramidal Tracts, on page 549, with 
the exception that in that disease, where the lesion begins primarily 
in the spinal cord, both legs are affected, while in the disease under 
consideration the degeneration of the motor tract is mainly limited to 
the entire lateral pyramidal tract of one side, so that the symptoms 
are manifested in the arm and leg of that side only. As a cerebral 
haemorrhage usually takes place in the motor tract above the decussa- 
tion in the pons, the descending degeneration will not be entirely 
limited to the lateral pyramidal tract. A portion of the cerebral 
motor fibres do not decussate, but continue downward in the same 
side of the cord in what is known as the columns of Ttirck, or the 
anterior pyramidal tract (Fig. 70, page 554). 

This column probably connects with the cells in the anterior horn 
of gray matter of the same side. Usually the anterior pyramidal 
tract contains but a small proportion of the cerebral motor fibres, 
hence the three cardinal symptoms of inflammation of the spinal 
motor tract — that is, stiffness, exaggerated tendon reflexes, and the 
ankle clonus — will be very slightly defined on what is usually termed 
the sound side. Most frequently stiffness «g not appreciated on that 
side at all, the knee-jerk is found to be slightly exaggerated, and 
there may be a tendency to the ankle clonus, which, however, is sel- 
dom well marked. 

Atrophy of the paralyzed muscles may be one of the secondary 
results of brain-disease ; as we have seen, it is of a primary spinal 
affection. 

When the cord itself is the seat of primary disease, the lateral col- 
umns below undergo degeneration, and the muscles become perma- 
nently contracted. Many cases of distortion which ensue on sclerosis, 
tumors, and other lesions, are the result of this secondary degenera- 
tion. M. Charcot is of the opinion that the epileptiform attacks 
sometimes met with in hemiplegics may result from these secondary 
descending degenerations affecting the peduncles, the pons, and the 
medulla oblongata. 

No symptoms referable to ascending secondary degenerations — 
those of the posterior columns — have been recognized except in a few 
instances, and then the symptoms differ but little from those previ- 
ously described under the heading of Locomotor Ataxia. 

Causes. — Secondary descending degeneration of the spinal cord 
may result from primary lesions of the cerebral motor cortex, of the 
motor fibres of the internal capsule, of the pons Varolii, of the me- 
dulla oblongata, and of the spinal cord itself. Secondary ascending 
degeneration of the posterior columns is caused by disease of the 
posterior roots of the spinal nerves, and from lesions originating in 
some other part of the cord gradually extending in area until the pos- 
terior columns become involved. The immediate causes are the loss 



SECONDARY INFLAMMATION AND DEGENERATION. 609 

of the due supply of arterial blood, and the arrest of nutritive action 
from deficient nervous influence. 

The Diagnosis calls for no special consideration. 

Prognosis. — This is very unfavorable. Cerebral motor nerve-fibres 
whose continuity is inter.upted by any lesion which separates them 
from the cortical nerve-cells which supply them with their nutrition, 
invariably degenerate. This degeneration consists of an inflamma- 
tory destruction of the nerve-fibres, with a consequent proliferation 
of new connective tissue, and is termed sclerosis. Unless it is pos- 
sible to restore the destroyed nerve-fibres, and to resolve the hard- 
ened and increased quantity of connective tissue to its normal con- 
dition — which it is very evident we cannot do — it can be seen at a 
glance how utterly hopeless is the prospect of even an amelioration 
of the symptoms. 

Morbid Anatomy and Pathology. — Secondary degeneration is gen- 
erally found in the white substance, the gray being seldom affected. 
This might certainly have been expected, owing to the fact that it is 
the conducting power of the cord only that is lessened, and, as this 
power resides almost entirely in the fasciculi of the white substance 
in the lateral pyramidal tract and posterior columns, it is here that we 
ordinarily find the lesions. When a fibre belonging to the white sub- 
stance is injured, either in the cord or in its intra-cranial prolonga- 
tions, the secondary degeneration ensues either above or below the 
seat of the primary lesion, but it extends through the entire length of 
this portion to its central or peripheral extremity, according as it in- 
volves sensory or motor filaments. To these two varieties the terms 
ascending and descending degeneration are applied. The affected 
fibres alone are changed, and the alteration extends throughout their 
whole length. But, as the white fibres are constantly receiving other 
fibres which have had no initial injury, the secondary degeneration 
becomes relatively less the greater the distance is from the seat of the 
primary lesion. 

The morbid condition depends upon three processes : atheroma of 
the capillaries and the formation of granular corpuscles in the degen- 
erated tissue ; the degeneration and atrophy of a greater or less num- 
ber of nervous filaments ; the proliferation of connective tissue which 
takes the place of the nerve-tubes. These changes are similar to those 
which occur in the several forms of sclerosis, to which attention has 
already been directed, and are essentially inflammatory in character. 

The explanation of the rigidity of the muscles, the presence of 
contractures, of exaggerated tendon-reflexes, and of the ankle clo- 
nus, is identical with that which has been given for this same group 
of symptoms described under the heading of Morbid Anatomy and 
Pathology, in the chapter on Primary Sclerosis of the Lateral Pyram- 
idal Tract. 

40 



610 DISEASES OF THE SPINAL CORP. 

When there is atrophy of the paralyzed and contracted muscles as 
a result of secondary degeneration of the cord, we may be very sure 
that the anterior horns of gray matter are involved. Charcot 1 cites a 
case which he reported to the Societe de Biologie, in which a woman 
aged seventy was suddenly struck with left hemiplegia, occasioned, as 
the post-mortem examination showed, by a cerebral haemorrhage seat- 
ed in the centrum ovale of the right hemisphere. Contraction of the 
paralyzed muscles supervened very soon, and, two months after the 
attack, the muscles of the inferior as well as of the superior extrem- 
ity began to atrophy at the same time that their electric contractil- 
ity was notably diminished. The muscular atrophy advanced with 
great rapidity, and simultaneously the skin on the paralyzed parts, 
when submitted to pressure, was the seat of numerous bullae and even 
erosions. 

The examination of the spinal cord revealed the existence of a 
descending sclerosis, occupying the left side, and presenting its ordi- 
nary features. But in addition, at several points of the cervical 
and lumbar enlargements, the anterior horn of gray matter of the 
same side exhibited evidences of an inflammatory process, and at 
these points the large nerve-cells had undergone a marked degree of 
atrophy. 

Similar cases have been reported by Hallopeau. 

Treatment. — The best results in my experience have been obtained 
from the use of the primary galvanic current to the cord, the same or 
the induced current to the muscles, forcible extension and flexion of 
the contracted limbs, and the internal administration of nitrate of sil- 
ver and cod-liver oil. It will generally be found that the opposing 
muscles are more or less paralyzed, and that great good may be effect- 
ed by stimulating them with the primary or induced currents. The 
division of tendons is never necessary, unless for the rectification of 
distortions of the toes or fingers. Sometimes the toes are strongly 
flexed against the sole of the foot, rendering it almost impossible to 
walk, from the pain produced by the dorsal surface being brought in 
contact with the ground, and hence obliged to bear the weight of the 
body. In such cases the tendons may with propriety be divided, un- 
less the toes can be kept extended by some convenient prothetic appa- 
ratus, or, as in the case under my care, to which reference has been 
made, the toe may, if necessary, be amputated. — Passive exercise of 
the affected muscles will do much to restore them. 

1 " Le9ons sur les maladies du systemc nerveux," 1874, p. 245. 



NON-INFLAMMATORY SOFTENING OF THE SPINAL CORD. 611 
CHAPTER VI. 

NON-INFLAMMATORY SOFTENING OF THE SPINAL CORD. 

Softening of the spinal cord is, as we have seen, the common 
termination of acute myelitis, in which connection it has been suf- 
ficiently considered ; but it may originate primarily, and in that 
event possesses a clinical history very distinct from that of acute 
inflammatory softening. 

Symptoms. — The first symptom usually noticed in softening of the 
spinal cord is numbness in those parts of the body below the seat of the 
lesion. Soon after the occurrence of this symptom there is weakness of 
the same parts, and then the deficiency of sensation and the feebleness 
of motor power advance together, both gradually becoming more and 
more strongly marked. There are no muscular twitchings, no contrac- 
tions of the limbs, no pains either at the seat of the disease or in the 
paralyzed limbs. 

The bladder very soon becomes involved, and the patient finds that, 
when he attempts to urinate, the stream is not so strong as it once was, 
and that he is obliged at times to use the expulsive force of the abdomi- 
nal muscles in order to complete the evacuation of the bladder. Gradu- 
ally the contractile power of this viscus becomes less, and finally is 
altogether lost. 

The sphincter generally participates. The desire to urinate becomes 
more frequent, and when the inclination is felt the patient must at once 
yield to it. Eventually the bladder likewise becomes entirely paralyzed, 
and then there is neither the ability to expel the urine nor to retain it, 
and consequently it dribbles away constantly. 

Sometimes the first evidence of softening of the cord is perceived 
either in the bladder or its sphincter, and it may be restricted to these 
parts for a considerable period. I have a patient at the present time 
under treatment for what I have no doubt is softening of the cord, and 
in whom the bladder-troubles were the only notable symptoms for over 
two years. 

The intestines are similarly affected, and the bowels are either ob- 
stinately constipated or the sphincter ani is relaxed, leading to fecal 
evacuations as soon as the contents reach the rectum. 

Reflex excitability is weakened from the first, and gradually 
disappears, unless, as is rarely the case, the gray matter be un- 
affected. 

The progressive advance of the disease reduces the patient to a 
condition of utter helplessness. He is unable to walk, sensation is 
abolished in the paralyzed limbs, his urine and fasces are passed in- 



612 DISEASES OF THE SPINAL CORD. 

voluntarily, bed-sores occur, the venereal appetite is extinct, or, if 
it should remain, erections are impossible, and the parts of the body 
below the seat of the disease are to all intents and purposes cut off 
from communication with the parts above. This condition may last 
for years without a fatal termination ensuing, but intercurrent affec- 
tions, especially resulting from the bladder troubles, may eventually 
cause death. 

Such is the course of spinal softening when the lesion is low down 
and involves both antero-lateral and posterior columns. When it is 
higher up, the symptoms are also referable to the thoracic extremities, 
and to the muscles concerned in deglutition and respiration. There 
are likewise visceral disturbances. 

When the lesion mainly affects or is confined to the lateral pyram- 
idal tract, the symptoms manifested are in intimate relation with the 
known physiological functions of the region in question. Thus the 
power of motion in the limbs below the softened portion of the cord 
gradually becomes less, the gait is from the first staggering, and, though 
even at a late stage the patient may be able to move his limbs while 
lying down or sitting, he cannot support the weight of his body upon 
them. When he tries to stand without extraneous aid, it is seen that 
he is especially weak in the knees and ankles. There is no more diffi- 
culty in standing or walking with the eyes shut than when they are 
open. 

This paralysis of motion, in which the bladder generally participates, 
may be of the most profound degree, and yet sensibility be perfect. 
A gentleman was under my care in whom I diagnosticated softening of 
the cord in that part extending on the right side from the second dorsal 
vertebra downward probably as far as the fourth sacral, while on the 
left side it began at about the fourth lumbar and extended downward 
probably as low as the fourth sacral. I gave the lesion these topo- 
graphical limits for the reason that on the right side the muscles sup- 
plied by the crural and sciatic nerves had lost their electro-muscular 
contractility, while it certainly did not extend above the origin of the 
ilio-hypogastric nerve, as the lower part of the rectus abdominis, which 
receives its motor power through this nerve, retained its contractile 
power. On the left side the muscles supplied by the crural nerve were 
possessed of their normal motor power, while those supplied by the 
sciatic had lost their contractility. It was, therefore, very certain that 
on this side the lesion did not extend above the fourth lumbar, the 
lowest spinal nerve contributing to the formation of the crural. 

I was able also to restrict the morbid process entirely to the antero- 
lateral columns, for in no part of the skin below the upper supposed 
limit of the lesion was there any loss of sensibility. The least impres- 
sion made upon the skin was felt. Tickling the sole of the foot excited 
laughter, but no reflex movements. I was therefore able to determine? 



NON-INFLAMMATORY SOFTENING OF THE SFINAL CORD. 613 

that the gray matter was involved. The bladder was paralyzed, and 
its sphincter likewise. The sphincter ani was also deprived of its con- 
tractile power to a great extent. 

The patient died at Cape May, and I had no opportunity of making 
a post-mortem examination. Probably, however, the lesion was essen- 
tially that which I have described. In all cases of spinal softening in- 
volving the antero-lateral columns, the electro-muscular contractility is 
soon lost, so that even the strongest induced or primary currents fail 
to cause contractions. 

As regards the implication of the posterior columns, there is an 
equal facility for determining the fact from a consideration of the symp- 
toms. The functions of these columns are intimately connected with 
sensation, and when such a morbid process as softening is set up in 
them the symptoms are those which indicate impairment of the cutane- 
ous and muscular sensibility. Thus, in a gentleman formerly under my 
charge, there had been going on for several months a morbid action in 
the spinal cord unattended by any prominent symptoms except anaes- 
thesia. There had never been pain or any derangement of motility, 
but simply a gradually-increasing loss of sensibility in both lower ex- 
tremities and in all the other parts of the body below the upper limit 
of the seat of the lesion. 

He was unable to walk in the dark or with his eyes shut, or to stand 
alone with his eyes closed and his feet close together, for he obtained 
no idea of his position unless he could have the aid of his eyes or hands. 

He had full power over the bladder and voluntary control over its 
sphincter and that of the rectum, but he never experienced the desire 
to urinate, did not feel the flow of urine through the urethra, nor the 
passage of the fseces through the anus, and evacuated his bladder and 
bowels at stated periods merely from the knowledge acquired by ex- 
perience that it was time to do so. 

Examination with the sesthesiometer showed that the upper limit of 
the lesion on both sides was in that part of the cord from which the 
second lumbar nerves are derived, for the loss of sensibility was appar- 
ent in all those parts supplied by the crural and sciatic nerves, both as 
regarded the skin and the muscles. Very weak faradaic currents caused 
muscular contractions, but the strongest which it was possible to ob- 
tain from a powerful machine produced no pain. 

There was no muscular incoordination, neither had there ever been 
electric-like pains in any part of the body. The patient died in 1873. 
For a year previously he had exhibited indications of insanity, and 
finally committed suicide by hanging himself to his bedpost. A post- 
mortem examination was made of his brain, but the physician who then 
had charge of the case thought it too great a trouble to examine the 
cord, and thus an opportunity for studying what must necessarily have 
been important lesions was lost. 



614 DISEASES OF THE SPINAL CORD. 

In this case there was, I think, ample reason to diagnosticate a 
lesion of the posterior columns without any implication of the antero- 
lateral. The reasons for believing this lesion to have been softening 
will be indicated under the head of diagnosis. 

Causes. — The causes of spinal softening are not very clearly under- 
stood. Doubtless it arises as a consequence of acute myelitis, but it is 
often an independent and apparently a primary affection, being unpre- 
ceded by any obvious symptoms indicative of spinal derangement. 
Such influences as give rise to cerebral softening will, in all probability, 
cause spinal softening, and among them must be placed obliteration of 
blood-vessels from embolism and thrombosis. The actual occurrence of 
occlusion of spinal vessels from either of these causes has not, however, 
so far as I am aware, been demonstrated. The further etiology of spi- 
nal softening is not as yet a matter of any certainty, though I think 
several cases that have been under my observation could reasonably 
have their cause laid to excessive sexual indulgence. 

Diagnosis. — The diagnostic marks of most value in cases of sup- 
posed spinal softening are the absence of sensory and motor excite- 
ment. Thus there are no pains referable to the back or other parts of 
the body, no hyperesthesia, no twitchings, no spasms, no contractions, 
no exalted reflex actions. And this is the case in that form of the dis- 
ease involving the whole thickness of the cord, or in either of those 
limited to the anterior or posterior columns. There is no other affec- 
tion of the spinal cord which is not characterized, at some time or other 
of its progress, by irritation either of the sensory or motor nerves, or 
of both, excepting some cases of spinal anaemia giving rise to the cate- 
gories of symptoms previously considered. The clinical history of such 
cases, and the comparatively light character of the phenomena, will 
serve to distinguish them from those in which the lesion is softening. 

Prognosis. — The prognosis is always unfavorable as regards recov- 
ery and complete restoration, but spinal softening is not necessarily 
a fatal disease. At least, I have seen cases which had existed for many 
years, and which apparently had no elements of a fatal termination 
about them. But they were instances in which the seat of the disease 
was in the lower dorsal, or lumbar or sacral region of the cord. When 
it is higher up, the prospect of death ensuing is more probable. The 
restoration of the cord to its normal structure is impossible, and the 
patient lies paralyzed either in sensation or motion, or both, according 
to the situation and extent of the lesion, in a condition similar to that 
of a person who has received a wound inflicting irreparable injury on 
the cord. Such persons, as is well known, frequently live for many 
years afterward — then die of some entirely different disease. There is 
nothing about spinal softening calculated to produce exhaustion, un- 
less it be the tendency which exists to cystitis from paralysis of the 
bladder, and the consequent inflammation liable to be set up from the 



NON-INFLAMMATORY SOFTENING OF THE SPINAL CORD. 615 

action of the retained urine. Care, however, will very greatly diminish 
the danger from this source. I have had a number of patients under 
my charge who had not, for many years, had a passage of urine from 
the bladder which was not effected with the catheter, and they had, in 
all that time, suffered no marked inconvenience. 

Morbid Anatomy and Pathology. — The appearance of a softened 
portion of the spinal cord to the naked eye has nothing very peculiar 
about it. When examined as to its consistence, it is seen to be some- 
times as soft as cream, at others scarcely altered in the resistance which 
it offers to the touch. In the first instance, when the lesion involves 
the gray and white matter together, section does not show the peculiar 
double crescentic arrangement of the former tissue, but it appears to be 
blended homogeneously with the white substance which surrounds it. 

Microscopically it is seen that the nervous tubules constituting the 
essential anatomical elements of the white substance are broken up, 
and no vestige of them remains in extreme cases — oil-globules and 
bodies called granule-masses, the constituent of which is fat, having 
taken their place. In the gray substance the nervous cells are de- 
stroyed, and oil and fat have made their appearance in large amount. 
Even the neuroglia or connective tissue of the cord exhibits a similar 
disintegration and regressive metamorphosis. These changes impair 
the functions of the cord, both as a nervous centre and as a structure 
serving for the transmission of sensory impressions to the brain, and of 
nervous force from it. When the disintegration is complete, the effect 
is the same as if the cord had been entirely divided by a cutting in- 
strument. 

Treatment. — There is nothing to be done which can by any possi- 
bility restore the integrity of the spinal cord after the process of soft- 
ening has fairly entered upon its course. In the very early stages, if 
patients apply for treatment at these times, something may perhaps be 
accomplished by the use of phosphorus and strychnia, but the symp- 
toms come on so insidiously and gradually that the subject of them 
rarely has his apprehensions excited till it is too late to do any thing 
toward arresting the disease. And even when we do see cases which 
in appearance exhibit the symptoms met with in spinal softening in its 
initial stage, and which recover under treatment, there must always be 
a doubt in regard to the accuracy of the diagnosis — for many cases of 
temporary anaesthesia and impairment of motility are due to anaemia of 
the cord, the result of the causes set forth in a previous chapter. 

The patient, however, may be made comfortable to such an extent 
as to materially prolong his life. Care should to this end be taken 
that he does not sustain a fall or suffer an injury whereby the diffluent 
portion of the cord would be disturbed in its anatomical relations, and 
the danger of an attack of acute meningitis or of myelitis incurred. 
Bed-sores should be prevented, or, if they occur, treated according to 



616 DISEASES OF THE SPINAL CORD. 

the methods previously mentioned, and full instructions should be 
given in regard to emptying the bladder with the catheter at regular 
times, and of going to stool at the same hour every day. Locomotion 
may be provided for by some one of the chairs devised for the use of 
paraplegics. As there is little, in softening of the cord situated below 
the origin of the phrenic nerves, which is directly calculated to de- 
stroy life, there is no reason why, with the adoption of proper meas- 
ures, the patient should not enjoy a measurable degree of comfort for 
many years. Probably the event most apt to occur is acute or chronic 
cystitis from paralysis of the bladder, but attention to the injunction 
above given will do much toward lessening the liability to this affec- 
tion. 



CHAPTER VII. 

TUMORS OF THE SPINAL CORD. 

Following the example of Jaccoud, I shall consider under one head, 
tumors of the cord, of the membranes, and those which, growing from 
the interior surfaces of the vertebrae, may compress the cord, and thus 
interfere with its functions by deranging its structure. In the present 
state of our knowledge, we have not many exact data by which to dis- 
criminate between these several growths. 

Symptoms. — The phenomena which result from intra-spinal tumors, 
like those due to congestion, are of two categories, resulting as they do 
either from irritation or compression. Under the first head are em- 
braced pain in the back, in the limbs, and in the viscera, if the poste- 
rior columns are mainly the seat of the lesion or subjected to the press- 
ure of a vertebral tumor, and twitchings of the muscles, and contrac- 
tions of the limbs, if the antero-lateral columns are principally involved. 
When both sets of columns — as is generally the case — are affected, the 
troubles of sensibility and of motility are both present. 

If the tumor is situated in the cervical or upper dorsal region, there 
is generally tonic contraction of the muscles of the neck by which the 
head is thrown backward, causing the patient to present the appear- 
ance of a person affected with the opisthotonos of tetanus. There are 
in such a case usually ocular troubles, such as those previously men- 
tioned, and more or less gastric derangement. The symptoms, so far 
as the limbs and viscera are concerned, vary in their extent according 
to the situation of the morbid growth. 

The symptoms of strong compression are anaesthesia and motor pa- 
ralysis. These may or may not be accompanied with muscular atrophy. 
Reflex excitability and electro-muscular contractility are generally at 
first increased, or at least not lessened, but, as the pressure augments 



TUMORS OF THE SPINAL CORD. 61 7 

and the structure of the cord becomes more disorganized, they are less- 
ened. 

The bladder generally retains its power, but if the tumor be situated 
so as to compress the middle of the dorsal region there will be more or 
less difficulty in passing the urine which is retained through spasm of 
the sphincter. If the lesion exists at the upper part of the lumbar re- 
gion, or at about that part, the bladder and sphincter will be paralyzed, 
and the urine will dribble continuously. 1 

Many cases, of what may with Drs. Charcot and Brown-Sequard be 
called hemi-paraplegia, are due to spinal tumors. It often happens 
that these are small and compress a lateral half of the cord, leaving the 
other affected only by the transmitted pressure. A very remarkable 
case has been reported by Charcot, 2 in which the left inferior extremity 
was completely paralyzed, while the right was simply weak without 
having lost the power of contraction in any of its muscles. On the 
other hand, sensibility was greatly lessened in the right limb, while it 
was exalted in the left. There was paralysis of the bladder, but no at- 
rophy of either limb. Finally, anasarca and bed-sores appeared, and 
the patient gradually sank. On post-mortem examination, a tumor 
was found growing from the dura mater on the anterior face of the 
cord and compressing its left lateral half. The accompanying wood- 
cuts (Figs. 87 and 88), reduced from Charcot's lithographic repre- 
sentations, show the situation and relations of this tumor. Fig. 87 
shows the growth in sitxr, and Fig. 88 the parts as they appeared 
when the tumor was pushed aside so as to allow the cavity to be seen 
in which it was lodged. 3 

Recollecting the facts that the fibres of the anterior or motor col- 
umns of the cord decussate at the medulla oblongata, while those of 
the posterior or sensory columns cross over soon after they enter the 
cord from the posterior roots of the spinal nerves, we can understand 
why, when the paralysis of motion is confined to one side, or is greater 
on that side, the lesion is on the corresponding side of the cord, 
and this loss of motility should be accompanied with anaesthesia of the 
opposite side of the body. 

Under the name of painful paraplegia (parapl&gie douloureuse), 
Cruveilhier referred to a form of spinal disease which has been subse- 
quently described more fully by Charcot. This latter author has ob- 
served six cases, in all of which there was cancer of the mammary gland. 
In three of these he had the opportunity of making post-mortem ex- 

1 Charcot, "Lecons sur les maladies cm. systeme nerveux ; secemde fascicule. De la com- 
pression lente de la moelle epiniere," Paris, 1873, p. 114. „ 

2 Archives de physiologie, No. 2, p. 291. 

8 This case is quoted at length by Dr. Brown-Sequard in the Lancet of September 25, 
1869, p. 429. In previous and subsequent numbers of this journal Brown-Sequard baa 
contributed much valuable information on the subject of hemi-paraplegia. 



018 



DISEASES OF THE SPINAL CORD. 



animations, and discovered carcinoma of a lumbar vertebra in each, to 
which the irritation and compression of the cord were due. According 
to him, " the skin, especially during the paroxysms of pain, is often 



Fig. 87. 



Fio. 88. 







very sensitive to the touch. At the same time walking becomes trouble- 
some, and later the patient cannot walk without help; finally, muscular 
atrophy ensues, and the patient loses the power to stand." 

Simon, from whom I quote these details, under the head of " para- 
plegia dolorosa," describes a case which came under his own observa- 
tion, in which, during life, symptoms similar to those mentioned by 
Charcot were noticed, and in which, after death, a cancerous tumor 
was found growing from the first lumbar vertebra and compressing the 
posterior columns of the cord. Other lesions were present in the pos- 
terior columns both above and below the tumor ; they were appar- 
ently of the nature of sclerosis. Similar cases have been described by 
other authors. 

Although it is rendered certain that cancerous tumors of the verte- 
brae may give rise to paraplegia characterized by great pain, it must be 
borne in mind that these symptoms are not a necessary accompaniment 
of the lesion, and that they are met with in other affections of the cord. 



TUMORS OF THE SPINAL CORD. 619 

A tumor situated in the cervical or upper dorsal region of the cord 
sometimes gives rise to characteristic symptoms. Thus there may be 
dilatation or contraction of the pupil on one or both sides, or one may 
be contracted and the other dilated. Cough and dyspnoea, vomiting, 
difficulty of swallowing, epileptiform convulsions, and a remarkable 
slowness of the pulse, are sometimes among the phenomena. But such 
symptoms are by no means invariable. Many years ago Velpeau ? re- 
ported a case of tumor of the cervical region of the cord in which none 
of these symptoms were present. The patient, a woman at thirty-four 
years of age, after having experienced mental troubles and been ex- 
posed to bad hygienic influences, suffered from convulsive movements 
of the limbs which were not of long continuance. Shortly afterward 
the left arm became the seat of a severe pain, and she had pains in the 
head. The pain in the arm increased, and little by little she lost the 
use of the limb. Renewed convulsive movements occurred in the in- 
ferior extremities, and were followed by complete paralysis. When she 
presented herself at the hospital she had no pain in the left arm, which 
was, however, entirely paralyzed, but which, nevertheless, retained its 
sensibility almost unaltered. Motion of the right arm, though difficult, 
was still possible, but it was the seat of very severe pain. Respiration 
was normal but a little weak; the pulse was frequent, sometimes strong, 
but generally small and regular. There was a large and deep ulcera- 
tion on the sacrum; the lower extremities were anasarcous and were de- 
prived of all sensation and power of motion. The fecal matters and the 
urine were passed involuntarily and unconsciously. Gradually she lost 
the ability to move the right upper extremity. She sank almost im- 
perceptibly without apparent cause, and died after having been two 
months and a half in the hospital. 

On post-mortem examination numerous whitish opaline plates were 
found scattered over the arachnoid, but the principal lesion consisted 
of a tumor, which was situated between the arachnoid and the cord, and 
covered the entire anterior surface of the latter from the sixth cervical 
pair of nerves to the third dorsal. This growth appeared to have its 
origin in the left antero-lateral furrow. The anterior roots of the left 
spinal nerves within its area were so compressed that they were shrunk 
to mere threads, and the posterior roots of the same side were also sub- 
jected to pressure. The right posterior roots were in a normal condi- 
tion. The whole body of the cord was flattened by this tumor, but the 
left side was especially in this condition. The growth was cerebriform 
in appearance, and was thought to be cancerous. 

As an example of the symptoms resulting from a tumor occupying 
the dorsal region of the cord, the following, from Ollivier, 2 is cited : 

1 " Observation sur une maladie de la moelle epiniere tendant a demontrer 1'isolemeDt 
des fonctions des ratines sensitives et motrices des nerfs," Journal de pJiysiologie de Ma 
^endie, tome vi., 1826, p. 138. 

2 "Traite des maladies de la moelle epiniere," Paris, 1837, tome ii., p. 477. 



620 DISEASES OF THE SPINAL CORD. 

A woman, aged fifty-two, had enjoyed good health till in 1819 she 
began to experience lancinating pains in the abdomen and breast. Af- 
ter several months these pains shifted their situation to the pelvis and 
the lower extremities, especially the left. These limbs then became the 
seat of varied phenomena, sometimes being cold, at others hot, and 
again numb ; they were also subject to the most intolerable itching. 
Then they became by turns immovable, and were agitated by convulsive 
movements. Although she could stand, walking was impossible. Fi- 
nally, in February, 1821, they began to atrophy, and at once lost all 
sensibility and power of motion. Then these symptoms disappeared, 
and there only remained numbness and pains apparently starting from 
the pelvis and traversing the nerves. In May, 1821, she entered the 
hospital. At this time the inferior extremities were rigid, and could 
not be flexed without causing pain of a very atrocious character. They 
were insensible to all external excitations, but were constantly the seat 
of severe and lancinating pains. There was, however, no pain along 
the vertebral column, and the general health of the patient was excel- 
lent. 

All these symptoms persisted till in January, 1823, the legs began to 
be flexed on the thighs, and these latter on the pelvis, to such an ex- 
tent that the heels pressed against the buttocks, and the knees touched 
the chest, Forced extension of the limbs was exceedingly painful, and 
when they were by main strength extended they at once returned to 
their former position as soon as the traction was discontinued. Two 
months before her death the left wrist and right knee became inflamed; 
the former suppurated, and the patient died six weeks afterward. 
Strychnia had been administered, but always aggravated the symp- 
toms. Morphia gave no relief. 

Examination after death showed the brain to be healthy. There 
was a band of sclerosed tissue on each side of the cerebellum. 

The spinal cord was healthy as far down as the tenth dorsal verte- 
bra. Here a tumor existed between the two layers of the arachnoid. 
The growth was oblong, and about two inches in length. It was simi- 
lar in appearance to brain-tissue, but firmer. It was not adherent to 
the cord, but throughout its whole extent pressed on the organ, which 
was softened throughout to the consistence of a thin jelly. At the 
most voluminous part of the tumor the cord was so much compressed 
that it was almost cut in two, so that there was the appearance of two 
cones with their apices together. A careful examination showed that 
in the softened part no trace of nerve-structure remained. 

Leyden, 1 among other interesting cases, gives the following, of tu- 
mor occupying the lower dorsal region of the cord : 

The patient, a woman twenty-nine years old, after being delivered 

1 "Klinik der Riickenraarkskrankheiten, 1 ' erster Band, Berlin, 1874, p. 454. 



TUMORS OF THE SPINAL CORD. 



621 



of a dead child, became affected with a pain in the right leg, which, 
starting from the foot, reached the knee, and finally settled in the calf. 
She noticed at the same time a weakness of this leg, which prevented 
her walking well, and eventually confined her to bed. These symptoms 
disappeared, and she remained well for over three years, when the right 
leg again became weak, and was the seat of constant lancinating pains, 
which were aggravated by muscular exercise. In April, 1872, the left 
leg was also affected with similar pains. It soon became impossible 
for her to bend the knee or to move the limb. All these symptoms in- 
creased until, in February, 1872, she was unable to walk, and there was 
complete anaesthesia in both extremities as high as the hips. A painful 
sensation of constriction was felt around the body at the umbilicus. 
The electric excitability of the right lower extremity was lessened, of 
the left was normal. The reflex excitability of both lower extremities 
was increased ; the nutrition was good. At times they were the seat 
of strong contractions. 

By August, 1873, the patient was entirely confined FlG - 89 - 

to bed on her back, and deprived of all voluntary move- 
ment of her lower extremities. There were, however, 
often paroxysms of tremor in both feet so strong as to 
shake the whole body, and at times powerful contrac- 
tions of the muscles, drawing the thighs against the ab- 
domen, while the knees were flexed to their utmost ex- 
tent. The constricting pain around the body was still 
present. 

In the beginning of October the patient was seized 
with typhus fever and died. On examining the spinal 
cord it was found that a tumor existed on the right 
side, reaching from the seventh to the tenth dorsal ver- 
tebra, and firmly attached to the dura mater. The en- 
tire length of this growth was eighty millimetres (a lit- 
tle over three inches). (Fig. 89.) 

Causes. — Nothing is known relative to the etiology 
of intra-spinal tumors beyond the fact that they may 
result from the syphilitic, scrofulous, and cancerous dia- 
theses, and from wounds and injuries. 

Diagnosis. — There are no certain marks by which 
we can determine with any great degree of certainty 
that a tumor is compressing the spinal cord. We may 
suspect such to be the case when the motor paralysis is 
more marked on one side of the body than the other, 
and the anaesthesia exists to a greater extent on the 
opposite side. The existence of either syphilis, scrofula, or cancer, in 
connection with spinal troubles not clearly referable to some other dis- 
ease, may likewise excite the suspicion that a tumor exists. But the 



622 DISEASES OF THE SPINAL CORD. 

symptoms — paralysis, hyperesthesia, anaesthesia, contractions, rigid- 
ity, and spinal convulsions — are met with in other spinal disorders, 
notably in symmetrical lateral sclerosis. The unilateral predominance 
of the phenomena is probably, on the whole, most to be relied upon 
as a diagnostic mark. 

Prognosis. — This is always unfavorable. It is less so when a 
syphilitic origin can be made out, and when the tumor is situated in 
the posterior or lateral portion of the membranes it may be removed. 
No others recover. 

Morbid Anatomy and Pathology. — The most common intra-spinal 

morbid growths are those which are developed from the vertebrae, and 
they include many syphilitic, scrofulous, and cancerous tumors. They 
originate either from the bones or from the periosteum. Formations 
resulting from either of these diatheses may also grow from the menin- 
ges or the substance of the cord. 

Parasitic tumors due to either the echinococcus or the cysticercus, 
may also be developed within the spinal canal. Their usual seat is in 
the membranes ; and, according to Ollivier, 1 the echinococcus is found 
in the spinal cavity of women only. 

Aneurismal tumors occasionally form in the intra-spinal arteries, and 
may compress the cord. Aneurisms of the thoracic or abdominal aorta 
may, by pressure, cause absorption of the vertebrae, and may thus 
eventually subject the cord to their influence. 

Among the other intra-spinal tumors are the glioma — a growth, the 
seat of which is especially in the brain and spinal cord, and whose struct- 
ure is very similar to that of sclerosed nerve-tissue — the sarcoma, the 
psammoma, the neuroma, fibroma, and myxoma, and tumors, generally 
syphilitic, developed from the vertebrae. 

Treatment. — The attempt should always be made, whenever the ex- 
istence of a tumor of the spinal cord is suspected, to effect its removal 
'by anti-syphilitic treatment, with iodide of potassium and mercury. 
The following case will show the advantages of following this course: 

In the summer of 1869 I was requested to visit a gentleman who, I 
was informed, was paraplegic and subject to paroxysms of great suffer- 
ing. On making my examination, I found his limbs contracted, his re- 
flex excitability augmented, and motor paralysis and anaesthesia of both 
lower extremities. There were intense pain in the lower dorsal region, 
and violent spasms of the sphincter vesicae, alternating with paralysis 
of it and the bladder. There were also paroxysms of severe pain in the 
head, and occasional attacks of delirium. He denied any syphilitic infec- 
tion, but, on examining his head with my hands, I found a gummy tumor 
of the scalp over the right occipital region. Further inquiry and ex- 
amination revealed the existence of a similar tumor over the leftiaoiius. 
I inferred that there might be one or more like growths within the 
: "Traite des maladies de la moelle epiniere," Paris, 1837, tome ii., p. 549. 



SYPHILIS OF THE SPINAL CORD AND ITS MEMBRANES. 623 

spinal canal, and I administered the iodide of potassium in gradually- 
increasing doses, with the bichloride of mercury in doses of the six- 
teenth of a grain three times a day. In less than two months every 
symptom of disease, except a general weakness, had disappeared. 
The tumor of the scalp went during the first month ; that of the arm 
a week later. The iodide of potassium was carried up to fifty grains 
three times a day. This patient continues in good health up to the 
present time. Even if there was not sufficient reason to diagnosticate 
the existence of an intra-spinal syphilitic tumor, the success of the 
treatment can scarcely leave a doubt on the subject. 

If this treatment fail, there is little else left. When the symp- 
toms point to compression of the cord by a tumor situated either in 
the membranes or in the spinal canal, the growth may be removed by 
operative procedure. This operation was first successfully performed 
by Horsley on a patient of Gowers's. 1 Since then, numerous opera- 
tions have shown that, under proper antiseptic precautions, the arches 
of several vertebras may be removed, the membranes opened, and the 
cord searched for a space of several inches with comparative safety. 
In this manner tumors have been removed in several instances. 

As means of mitigating the pain and spinal convulsions, hypoder- 
mic injections of morphia or atropia, or of both combined, may be 
employed. 



CHAPTER VIII. 

SYPHILIS OF THE SPINAL COED AND ITS MEMBEANES. 

When compared with like affections of the brain and its mem- 
branes, syphiHtic accidents of the cord and its envelopes are certainly 
rare. Of course, this statement has reference only to new forma- 
tions. As a cause of many of the affections described in the fore- 
going chapters, syphilis occupies, if not the first place, at least one 
very near the front rank. Locomotor ataxia, for instance, is proba- 
bly in the majority of instances of syphilitic origin ; and Dr. Gow- 
ers has recently gone so far as to declare that in his opinion syphilis 
is its only cause. 

As in the brain, neoplasms of syphilitic origin are known to be 
developed on the periphery of the cord rather than in its substance, 
in the subarachnoid space and on the internal face of the dura mater. 
Adhesions of the membranes to each other and to the substance of 
the cord are thus induced, while this latter is little by little invaded 
by the new formation. Generally the neoplasm does not appear as a 

1 British Medical Journal, January 28, 1888. 



624 DISEASES OF THE SPINAL CORD. 

well-defined tumor, but as a substance analogous to that of gummata 
diffused through the tissues. 

The histological and macroscopic characters are like those which 
are met with in like formations of the encephalon. Instead of a dif- 
fused infiltration, little miliary nodosities may be met with, dissemi- 
nated in the meninges. Engelstedt 1 has reported a case of this kind. 

Sometimes there is found at the postmortem examination of syphi- 
litic patients, who had during life presented evidences of spinal trou- 
bles, a kind of deposit replacing to a certain extent the cellulo-adipose 
tissue which lines the internal face of the spinal canal. From this 
there results an intimate adherence of the dura mater with the walls of 
this canal. Virchow has reported a similar case observed in an indi- 
vidual who had had multiple syphilitic accidents, and in the last pe- 
riod of his existence a painful rigidity of the neck and arms, which 
supervened on paralysis of the upper extremities. At the autopsy the 
dura mater was found considerably thickened at the height of the 
fifth and sixth cervical vertebrae, and adherent to the wall of the canal 
by a great quantity of tough connective tissue. 

At other times the exudation occupies the internal face of the dura 
mater, and this results in adhesions of the membranes to each other. 
At the same time the adjacent part of the cord is the seat of a hyper- 
plasia of the neuroglia with distention of the nerve-structures. Hue- 
ter reports a case of this kind. 

In cases of syphilitic patients who have died after having pre- 
sented symptoms of a spinal affection, a simple softening of the cord 
has been discovered. On the other hand, there have never been any 
absolute proofs that pure myelitis has ever been developed through 
the influence of syphilis. 

And in a certain number of cases the autopsy has never revealed 
the slightest appreciable lesion of the cord (Zambaco, Kussmaul, Leon, 
Gros, and Lancereaux). Spinal affections are generally exhibited at 
an advanced period of syphilis, and in individuals who present unde- 
niable traces of the diathesis with all the accompaniments of a more or 
less advanced cachexia. They are characterized by pains localized in 
the spine or radiating to the limbs, with various derangements of 
sensibility (formication, numbness, anaesthesia, etc.). Little by little 
rigidity of the muscles supervenes, and this is succeeded by temporary 
contractions and movements which gradually lose their energy, and 
are accompanied with painful cramps. All these symptoms, which are 
generally regarded as being due to meningitis, are subject to alterna- 
tions of amelioration and aggravation, and eventually all phenomena 
of excitation give place to paralysis. This generally first shows itself 
in one of the lower extremities, and advances with great rapidity. 
Yery soon the opposite limb is attacked, and the paraplegia becomes 

1 Archiv der Heilkunde, Band iv., 1863, p. 139. 



SYPHILIS OF THE SPINAL CORD AND ITS MEMBRANES. 625 

complete. Often the sphincters alone are involved. It is to be 
noticed that the paralysis of sensibility does not keep pace with 
that of motion, which, after existing for a long time, is supplement- 
ed by phenomena of anaesthesia or paresthesia. Then there is often 
a period of repose. At this period proper treatment may procure 
for the patient a gradual but nevertheless satisfactory cure. This 
termination is, above all, to be looked for when the lesion remains 
confined to the inferior part of the cord. The prognosis is much 
less favorable when the genito-urinary functions are involved. In 
such cases we ordinarily find that sooner or later cutaneous trophic 
troubles are developed over the sacrum — purulent cystitis, etc. — with 
all their consequences. Hectic fever is excited, and the patient dies 
greatly emaciated. 

When syphilitic lesions affect the upper part of the cervical region 
of the cord, patients are exposed to still greater dangers. In such 
cases the symptoms are very rapidly developed, for the paralysis 
involves all the muscles of the trunk, including the respiratory appa- 
ratus. The disease, in fact, follows a course analogous to that of 
acute ascending paralysis. In such instances a specific treatment 
instituted opportunely may still be sufficient to save the life of the 
patient, but cannot effect a complete cure. The tissues which have 
been infiltrated with the syphilitic exudations undergo a veritable 
inodular retraction and alteration, to which there are sometimes add- 
ed secondary ascending and descending degenerations. When the 
secondary degeneration affects the posterior columns, the paralysis 
may be replaced by certain manifestations of tabes dorsalis, but this 
syphilitic ataxia is not to be confounded with ordinary locomotor 
ataxia. 

In the cases of those patients in whom at the autopsy appreciable 
alterations of the marrow are not found, the spinal affection has 
generally followed a subacute course. It then greatly resembles 
the acute ascending paralysis of Landry. Sometimes its real charac- 
ter is recognized as being like that which is exhibited at an early 
period of syphilis, in the course of the first year after contamina- 
tion. Ordinarily it is not preceded by any prodromatic symptoms, 
but it is sometimes the case that a very short time after the devel- 
opment of the paralysis the affected limbs are the seat of vague 
pains. The paralysis begins in the lower extremities, and is com- 
plete after a few days. It is accompanied by a certain degree of 
weakness of the bladder, which is manifested either by incontinence 
or retention of urine. After the second week the patient is confined 
to his bed, and in a period relatively short he succumbs to septic 
infection. Therapeutics can avail nothing against this form of syphi- 
litic myelitis. 

41 



626 DISEASES OF THE SPINAL CORD. 

CHAPTER IX. 

SYRINGOMYELIA. 

It is only within the past few years that the attention of neurolo- 
gists has been drawn to the study of the symptoms produced by the 
formation of abnormal cavities within the spinal cord. That such 
cavities were of frequent occurrence has been known for many years, 
but recently the researches of Schultze in 1882, 1 and again in 1885, 2 
on the pathology of the disease, and further contributions to the 
clinical study of the disease by Baumler, 3 Buhl, 4 Starr, 5 Van Giesen, 6 
Jeffries, 7 and others, show that, at least in many instances, this dis- 
ease may be diagnosticated with accuracy. 

Symptoms. — As the disease usually begins in the cervical or upper 
dorsal regions of the cord, the first symptoms, under those circum- 
stances, will be observed in the upper extremities. 

The motor symptoms are progressive paralysis followed by atro- 
phy of the affected muscles. Sometimes whole groups of muscles 
supplied by one nerve are paralyzed simultaneously ; again one muscle 
after another may become affected. Fibrillary muscular twitchings 
are frequently observed, not only in the paralyzed muscles, but also in 
those muscles which are about to become paralyzed. Contractions of 
the unaffected muscles often follow, thus producing various deformi- 
ties, the most common of which is the wain en griffe. The electrical 
reactions show a quantitative decline consequent upon the diminished 
volume of muscular tissue, and the polar degenerative reactions may 
or may not be present. If the motor cells in the anterior horn of gray 
matter are involved in the destructive process, the polar degenerative 
reactions can readily be obtained ; otherwise they can not be. 

The superficial reflexes are generally abolished ; the knee-jerk is 
either normal or else slightly exaggerated. 

As far as the motor symptoms are concerned up to this point, they 
differ but little from those previously described under the heading of 
progressive muscular atrophy. In time, however, as the disease ex- 
tends so as to destroy a greater area of the cord, and more pressure is 
exerted on the surrounding tracts by the fluid within the cavity, the 
motor phenomena invade the lower extremities. These become weak ; 

1 Yirchow's " Archives," vol. lxxxvii. 

2 Ibid., vol. cii. 

3 Deutsche Archiv fur Hin. Med., Bd. xl, 1886. 

4 Archiv fur gen. Med., July, 1889. 

5 Am. Journ. Med. Sciences, May, 1888. 

6 Journ. Nerv. and Ment. Bis., July, 1889. 

7 Ibid., September, 1890. 



SYRINGOMYELIA. 627 

stiffness of the muscles supervenes ; the patellar tendon reflex is exag- 
gerated ; and the ankle clonus can frequently be obtained. Romberg's 
symptom, or the inability to stand upright with the feet close together 
and with the eyes closed, is sometimes observed. These symptoms, 
with the exception of the last one, are identical with those produced 
by inflammation of the lateral pyramidal tracts, and their presence in 
syringomyelia indicates that that tract has become implicated either 
from pressure or else from being involved in the diseased process. 

The sensory symptoms are not confined to the regions in which the 
muscular paralysis exists. The sensations of pain and temperature 
are abolished, while the sense of touch is preserved. There will 
be absolute anaesthesia for heat and cold, for pricking the skin and 
irritating it by strong electrical currents over the affected areas, and 
yet the individual can distinctly feel that the parts are touched, and 
can usually locate with considerable accuracy the spot where the 
touch was felt. Jacquet ! reports one case in which the tactile sense 
was destroyed together with the senses of pain and temperature. 
Pricking, stinging, and burning sensations are frequently complained 
of. The trophic and vaso-motor symptoms are not always well marked. 
Usually the affected limbs are cold and blue, and generally the secre- 
tion of sweat is diminished or abolished. Cuts and abrasions of the 
skin heal with difficulty, and ulcers and bed-sores which sometimes ap- 
pear are not amenable to the usual forms of treatment. The finger 
nails become brittle, and occasionally dislocations of joints and fract- 
ures of bones have occurred similar to those observed in locomotor 
ataxia. 

Causes. — Little is known in regard to the etiology of this disease. 
In some cases it seems to follow from injuries of the spinal cord, in 
others it develops in apparently healthy subjects who are not suffering 
from any congenital taint or predisposition. 

Diagnosis. — Syringomyelia may be confounded with hysteria, mul- 
tiple neuritis, progressive muscular atrophy, pachymeningitis, and pos- 
sibly with anaesthetic leprosy. 

From hysteria, syringomyelia can usually be differentiated by the 
history of the case, the presence in the latter disease of the reactions 
of degeneration, of fibrillary twitchings, and by the early appearance 
of muscular atrophy and the well-marked trophic and vaso-motor 
changes. 

In multiple neuritis the nerves are tender and are painful under 
pressure, the tactile sense is abolished with the other varieties of sen- 
sation, the disturbances of sensibility correspond in location with the 
disorders of motility, and there is usually a great deal of pain in the 
affected members which is augmented both by active and passive 
motion. 

1 Compt. rend, hcbdom. soc. de biol, Paris, tome ii, Xo. 3, 1890. 



628 DISEASES OF THE SPINAL CORD. 

In progressive muscular atrophy there are no abnormities of sen- 
sibility, no tendency to the formation of ulcers and bed-sores, and 
no diminution in the excretion of sweat. • 

Cervical pachymeningitis can be distinguished by the severe ten- 
derness and pain over the region of -the inflammation, and by the 
absence of the symptoms of disease of the central gray matter of the 
cord. 

Anaesthetic leprosy, though of very rare occurrence, at least in 
this country, bears some resemblance to syringomyelia. In one variety 
of the former affection — that is, the lepra nervorum — the senses of pain 
and temperature may be abolished while the sense of touch remains 
intact. If there are no accompanying skin lesions the differential 
diagnosis may be difficult or impossible. 

Prognosis. — No case of a cure has yet been recorded. The patient 
either dies from exhaustion or else the disease in its progress involves 
the upper regions of the cord, the perfect integrity of which is essen- 
tial to life. 

Morbid Anatomy and Pathology. — The formation of abnormal 
cavities within the spinal cord may depend upon any one of sev- 
eral morbid conditions. In childhood, hydromyelia, or the disten- 
tion of the central canal by fluid, sometimes occurs. Gowers 1 is in- 
clined to regard this condition as similar in nature to syringomyelia, 
and believes that both conditions are congenital. Schultze, 2 on the 
contrary, while admitting that a congenital defect is responsible for 
hydromyelia, considers that syringomyelia may develop in a healthy 
cord free from any hereditary predisposition. I have seen specimens 
of the former disease in which the tissues surrounding the dilated 
canal were healthy, the epithelial lining being plainly visible under 
the microscope. Syringomyelia may develop from haemorrhage into 
the cord, from softening of the cord followed by absorption, from sar- 
coma, and from gliomatous tumors. The latter is by far the most 
common. According to Schultze, it begins with an infiltration of 
gliomatous cells, usually in the neighborhood of the central canal, and 
confines itself almost entirely to the gray matter. The pressure thus 
brought to bear upon the surrounding tissues gradually destroys them. 
The gliomatous mass thus formed eventually breaks down and be- 
comes absorbed, leaving a cavity the walls of which are lined with 
connective tissue. The accompanying illustrations, Fig. 90 and Fig. 
91 (after Van Gieson), show the position of the cavity in the cord in 
his case, and also sections of the cord made at different levels. 

The infiltration is not always of a gliomatous nature. Berkley 3 
reports a case in which there was a dense hyaline infiltration which 

1 " Diseases of the Nervous System," p. 422. 

2 Zeitschrift fur klin. Med., No. 13, 1887. 

3 Brain, London, 1889-1890, vol. xlviii. 




Fig. 90.— Syringomyelia. (Van Giesen.) 





*$ 



& 



V 




M^h 



t---x 




»<s 






'^±x 






Fig. 91.— Syringomyelia. (Van Giesen.) 



PSEUDO-HYPERTROPHIC PARALYSIS. 629 

seemed to exude from the blood-vessels, which after absorbing, and to 
a great extent destroying, the surrounding tissue, broke down itself 
and was absorbed, leaving a cavity. Chemical tests showed that the 
exudation was hyaline. He refers to Huten, Steudener, and Langhaus 
as having observed similar pathological changes. 

In some instances the cavity in the cord is undoubtedly a congeni- 
tal defect. Van Gieson ' reports a case of this kind. But I am in- 
clined to the opinion that the majority of cases develop in subjects 
whose spinal cords were previously normal. 

Treatment. — There is very little to be said on this subject. The 
very nature of the disease precludes the possibility of a cure being 
effected. The most that can be done is to relieve the symptoms of 
the disease and to make the patient as comfortable as possible. 

Electrization of the paralyzed muscles, rest, and a general tonic 
treatment, together with a full nourishing diet, will prove of some 
service, and may retard the progress of the disease. 



CHAPTER X. 

PSEUDO-IIYPERTROPHIC PARALYSIS. 

In the early editions of this work I considered this disease under 
the head of hypertrophy of muscular connective tissue, although treat- 
ing of it as one of the affections of the motor and trophic cells of the 
cord. But this view must now be abandoned, since the evidence of 
later years practically points to this disease as being essentially a 
myosis. The clinical similarity of this affection with diseases depend- 
ent upon lesions of the central nervous system is so obvious that no 
apology is necessary for inserting it in its present position. 

Although previously noticed, the first to thoroughly investigate the 
condition was Duchenne, 2 who described it under the name of paraplegic 
hypertrophique de Venfance de cause cerebrate. He has since designated 
it paralysie pseudo-hypertrophique^ ou rnyo-sclerosique* Jaccoud 4 
calls it sclerose mascidaire progressive (progressive muscular sclero- 
sis). Dr. Foster 5 terms it paral} T sis with apparent muscular hypertro- 
phy, and Barth 6 fatty muscular atrophy. 

1 Journ. Nerv. and Ment. Dis., July, 1889. 

2 "De 1' electrisation localisee," etc., Paris, 1861, p. 353. 

3 Archives Generates, etc., 1868. 

4 Op. cit., p. 365. 

5 Lancet, May 8, 1869. 

6 " Beitrage zur Kenntniss der atrophia musculorem lipomatosa," Archiv de}' Hcil- 
Icunde, 1871, p. 120. 



630 DISEASES OF THE SPINAL CORD. 

Symptoms. — The first symptom observed is weakness in the lower 
extremities, which causes an inability to stand steadily, or to walk 
without stumbling or falling. The legs are separated widely in stand- 
ing or walking, and thus a peculiar character is given to the gait, which 
somewhat resembles that of a duck. 

Very soon an enlargement of the calf of one of the. legs is perceived, 
the other before long is affected, and then the muscles of the thighs 
and gluteal region become involved. 

As the child stands or walks, a remarkable incurvation of the spine 
in the lumbo-sacral region is perceived, so that if, as Duchenne remarks, 
a plumb-line be allowed to fall from the most posterior part of the 
spinous process of a vertebra, it passes far behind the sacrum. He 
considers this phenomenon to be due to weakness of the erector muscles 
of the spine. The muscles of the trunk may become involved, as may 
also those of the upper extremities — the deltoids being the first affected 
in the majority of cases, and the progress being much slower than in 
the low^er extremities. 

With the advance of the hypertrophy the paralysis becomes more 
strongly marked, and finally the child is confined to the recumbent 
posture. Distortions from disturbance of muscular equilibrium may 
take place, and the attempt at flexion or extension becomes painful. 

Occasionally the skin over the affected parts presents a peculiar 
mottled appearance, such as would be produced in the healthy skin by 
exposure to cold. 

After a period which varies in duration from two to five or six 
years, the hypertrophied limbs may begin to diminish in size, and 
eventually they put on very much the appearance exhibited in infantile 
spinal paralysis. This does not appear to be a constant occurrence, 
but is markedly exhibited in a case now under my care. Sometimes 
the muscles which are attacked, as the disease advances from the lower 
extremities, do not become hypertrophied, but on the contrary diminish 
in volume as in infantile spinal paralysis. We thus have in the same 
individual some muscles paralyzed with coexistent hypertrophy, while 
others are paralyzed and atrophied. 

Electric contractility is always lessened, both to the induced and 
to the primary currents, but the polar degenerative reactions are never 
observed. The knee-jerk, from primary changes in the muscles, is 
gradually diminished and is finally abolished. 

The course of the disease is slow, its average duration being about 
five or six years. As it advances, there are symptoms indicating loss 
of mental power, and cerebral disturbance is sometimes also indicated 
by ocular troubles and pain in the head. 

Death takes place by the respiratory muscles becoming implicated, 
by exhaustion, or by some intercurrent affection. 

Weir Mitchell, in the Philadelphia Photographic Review, for 1871, 



PSEITDO-HYPERTROPHIC PARALYSIS. 631 

reported a case which has recently been reexamined by Dr. George 
S. Gerhard. 1 The most remarkable feature of the case, that of a boy 
now thirteen years old, is that the tongue and all the facial mus- 
cles, but particularly the temporals, are hypertrophied. His speech is 
altered from the enlargement of the tongue, and he has some difficulty 
in taking his food. There is also a somewhat more than normal car- 
diac impulse. As regards the hypertrophy of the facial muscles this 
case is remarkable, and would be unique, but for the occurrence of a 
like condition in a case of my own, in which the left side of the face 
is hypertrophied. 

In the case which came under my notice March 7, 1871, the patient, 
a boy seven years old, exhibited a great disinclination to learn to walk. 
At three years of age he could not stand longer than a few seconds, 
and even for this time he was obliged to spread the legs apart and to 
hold on to some article of furniture. It was not noticed till he was five 
years old that his legs were larger than was natural. The hypertrophy 
began in the right calf, then attacked the left, and then the glutei mus- 
cles, before affecting the muscles of the thighs. The upper extremi- 
ties are as yet unaffected, but the spinal curve is very evident. The 
accompanying woodcuts (Figs. 92 and 93) give a posterior and profile 
view of this boy, from photographs. He was unable to stand alone 
while the photographs were being taken, but the spinal curve is well 
shown, and the positions are those he spontaneously assumed. He died 
in the spring of 1875, with pneumonia, having been for the previous 
three years unable to stand or even sit. The muscles of the upper ex- 
tremities were paralyzed for two years before his death, but under- 
went rapid atrophy instead of enlargement, 

Another case, that of a bright, intelligent boy, six years of age, 
was brought to me May 3, 1871, at the suggestion of my friend Dr. 
Trask, of Astoria, who accompanied the patient. Several months pre- 
vious the child had been noticed to fall frequently while at play in 
the bouse, and to show weakness in the legs when ascending a stair- 
case. The parents were unable to account for this debility, for, as the 
father assured me, the legs were exceedingly well developed. As 
the boy stood in my consulting-room, I observed that he separated his 
legs to a greater than usual distance, and that as he walked he also 
kept them far apart, and that his gait was staggering. As soon as his 
trousers were removed I at once perceived the nature of his disease, 
for the calves of both legs were hypertrophied to an enormous extent, 
and the incurvation of the spine was well marked. The electro-mus- 
cular contractility was almost entirely abolished in the gastrocnemii 
and solei muscles, and notably lessened in the muscles of the thighs, 
the gluteal region, and the back. These latter were not hypertrophied. 
On the contrary, they appeared to be rather under than above the 

1 " Pseudo-hypertrophic Paralysis," Philadelphia Medical Times, Oct. 16, 1875, p. 31. 



632 



DISEASES OF THE SPINAL CORD. 



normal size, and they were in a very decided paretic condition. Thus, 
when I requested him to cross one leg over the other as he sat on a 
chair, he was unable to do so without seizing hold of the leg with his 



Fig. 92. 




hands and thus assisting with their strength, and, as he lay at full 
length on his back on the floor, he could not draw up his legs without 
great trouble, though he could flex the thighs with readiness. 

On measuring the calves at their greatest dimensions, I found the 
right to have a circumference of twelve and a quarter inches, and the 
left of eleven and a half inches. The right thigh, at its point of 
greatest circumference, measured but eleven and a quarter inches, and 
the left ten and three-quarters inches. I saw this patient again in the 
course of two months. The paralysis of the lower extremities had in- 



PSEUDO-HYPE RTROPHIC PARALYSIS. 633 

creased to such an extent as to cause walking to be very difficult. At 
every step he lifted the thigh almost to the line of a right angle with 
the body, for he had no power to raise the foot. The flexors of the 
thigh, upon the pelvis, did not therefore appear to be much weakened. 
The calves were of about the same size as before. The upper extremi- 
ties were still unaffected. 

I did not see this case again for nearly two years. The paralysis 
had then so far extended as to render walking impossible, but the arms 
were still strong, and bv their means the patient dragged himself along 
over the floor. The calves had diminished in size, and the extensor 
muscles of the foot had become atrophied to such an extent as to allow 
of the permanent elevation of the heels by the uncompensated action 
of the still incompletely-paralyzed gastrocnemii and solei. The thighs 
were now hypertrophied, as were also the glutei muscles. 

Accurately measured, the circumference of the calves was, for the 
right, eight and a half inches, a loss of three and three-quarters inches ; 
and for the left, eight and a quarter inches, a loss of three and a quarter 
inches. On the other hand, the right thigh measured, at its largest 
part, fifteen inches, an increase of three and three-quarters inches; and 
the left fourteen and three-quarters inches, an increase of four inches. 

I saw this patient again in the summer of 1874, a year after the last 
visit, when, in order to allow of his wearing a shoe, I divided the right 
tendo-achillis, with the result of bringing down the heel and perma- 
nently relieving the extreme condition of talipes equinus which existed. 
The calves had undergone still further atrophy, and the thighs were 
likewise beginning to shrink. There was a slight disposition to a con- 
traction of the flexors of the thighs, and the upper extremities were be- 
coming paretic. 

A year subsequently (July, 1875) I again saw this patient. He had 
then been using a steel apparatus, which enabled him to stand, or rather 
the apparatus stood, and, being strong, supported the completely-para- 
lyzed patient. The calves now measured, the right eight inches, and 
the left eight and a quarter inches in circumference — a loss from the 
first measurements of four and a quarter inches and three and a quarter 
inches respectively. The thighs had also lost greatly from their hyper- 
trophied condition of two years before. The right now measured, at 
its largest part, ten and a half inches, a loss of five inches, and the left 
ten inches, a loss of four and three-quarters inches. 

The upper extremities were decidedly weaker than they were a year 
ago, but there was as yet no hypertrophy. The patient could not even 
sit without support, and there was notable weakness of the muscles 
which maintain the erect position of the head. 

Throughout the whole of the period during which this patient has 
been under my observation, the mind has remained clear, and the gen- 
eral health has been excellent, circulation, respiration, digestion, and 



GU 



DISEASES OF THE SPINAL CORD. 



Fig. 94. 



urination, all being well performed. The cutaneous tactile sensibility 
and the sensibility to pain have not been in the least weakened. 

While these pages are going through the press, I have again (De- 
cember 2, 1875) examined this patient, whose general health began to 
show signs of giving way. To my astonishment, a feature presented 
itself which thus far is entirely exceptional. A second stage of hyper- 
trophy is going on ; the calves now measure, the right ten inches, and 
the left ten and a quarter. The thighs were not measured, but were 
very considerably larger than when I last saw them ; and the father, 
a very intelligent gentleman, said that the enlargement in the lower 
extremities had been going on for two or three months. The left 
side of the face was decidedly larger than the right. The patient 
was still unable to walk, stand, or sit alone, but was comparatively 

strong in the arms, and in good gen- 
eral health. His mind was remark- 
ably bright. 

At all my examinations except the 
last two, I removed, by means of Du- 
chenne's trocar, portions of the hy- 
pertrophied and atrophied muscles, 
the results of the examination of 
which will be given under the head 
of the morbid anatomy. 

Quite recently Dr. E. B. Richard- 
son, of Mount Sterling, Kentucky, 
has given me the details, with photo- 
graphs, of an interesting case of the 
disease under notice. The patient, a 
boy, is eight years of age, of average 
intelligence, though not capable of 
prolonged mental exertion. The dis- 
ease is of several years' duration, and 
he is slowly getting worse. His loco- 
motion is peculiar ; usually he walks 
with his hands grasping the front of 
the thighs, and his legs are drawn up 
suddenly, as if with strings fastened 
to his back. In ascending a stair- 
case, he does so with his hands on his 
thighs, and the same foot is always 
advanced first, and not each alter- 
nately. If sitting down, he raises 
himself by clasping the thighs strongly ; otherwise he cannot get 
up at all. 

The boy's father is a strong and robust man ; his mother is delicate, 




PSEUDO-IIYPERTROPIIIC PARALYSIS. 



635 



and has had seven children, of whom three are younger than the pa- 
tient. In two, at least, of the other children there is some enlargement 
of the gastrocnemii mus- 



cles and a general ema- 
ciated appearance of the 
upper extremities. With 
the birth of the last child 
the mother had puerperal 
mania, and, June 23d, had 
not fully recovered. She 
had a sister and a brother 
who were insane, and there 
is incurable insanity in 
collateral branches of her 
family. 

Fig. 94, from a photo- 
graph, shows well the atro- 
phy of the trunk and up- 
per extremities, the spinal 
curve, and the hypertro- 
phy of the gastrocnemii 
muscles. Fig. 95 exhib- 
its the remarkable position 
assumed by the patient 



Fig. 95. 




Fig. 97. 





just as he is about to rise from the sitting posture. The atrophy of 
the muscles of the chest and abdomen is also shown. 

The postures assumed when an attempt is made to change from a 



636 ' DISEASES OF THE SPINAL CORD. 

horizontal to a vertical position are characteristic. The movements 
are slow and labored, and are performed with difficulty. When the 
patient is extended at full length upon his back and is then told to 
arise, he slowly gets upon his hands and knees, then — still keeping his 
hands upon the floor — he gradually brings his legs into a vertical posi- 
tion (Fig. 96). The hands are then placed, one after the other, upon 
the knees, when, by " climbing up the thighs," as it is termed, the 
trunk is slowly raised to an upright position (Fig. 97). 

Causes. — The disease is one which is almost entirely confined to 
children, and boys are more liable than girls. Nevertheless, it is not 
a disease peculiar to very early infancy. Of thirteen cases observed 
by Duchenne, six are stated to have begun in first infancy, while in 
seven the inception occurred at from two to ten years. Cases have 
also been reported as occurring in adults. From a table containing an 
analysis of forty-one cases given by Dr. Webber, in his paper already 
cited, it appears that in one case the patient was twenty-six when the 
disease began, in one a few years under forty, and in one about twenty- 
eight. 

Duchenne expresses the opinion that a hereditary tendency some- 
times exists, and this appears to be the fact. Of the cases analyzed 
by Poore, in two, a maternal uncle and aunt had the disease ; in one, 
three maternal uncles and aunts were affected ; in one, one maternal 
uncle and one half-uncle ; in one, three maternal half-brothers ; and in 
one, a maternal half-brother, three maternal uncles, and other members 
on the mother's side. 

The disease does not appear, therefore, to be transmitted directly 
from parent to offspring, but is a marked example of atavism. The 
descent is always from the mother's side. 

As to exciting causes, little or nothing is known. In none of my 
cases could any reasonable explanation of its etiology be given. There 
is some reason for ascribing it occasionally to exposure to cold an*d 
dampness, and to antecedent febrile diseases. 

Diagnosis. — The only affection at all resembling that under consid- 
eration is simple muscular hypertrophy due to an excessive supply of 
blood being sent to a part of the body. The histories and phenomena 
of the two disorders are, however, so very different, that I do not see 
how any error can arise in making a diagnosis between them. Never- 
theless, it is tolerably certain that 'mistakes on this point have been 
made. Thus, such cases as the one reported by Mr. Maunder, 1 which 
was clearly one of muscular hypertrophy possessing no analogies with 
the disease under consideration, have to my knowledge been regarded 
as instances of the disease under notice. 

Duchenne, 2 under this bead, gives very elaborate directions for the 

1 Medical Times and Gazette, March 27, 1869. 

2 Op. cit., and "De 1' electrisation localisee," troisierne edition, Paris, 1872, p. 608. 



PSEUDO-HYPERTROPIIIC PARALYSIS. 637 

discrimination of cases of pseudo-hypertrophic paralysis from those of 
progressive muscular atrophy occurring in infants, infantile paralysis, 
and the tardy development of the coordinative and motor. functions in 
young children. But it appears to me that very slight inquiry and 
examination will suffice to make errors in regard to any of these con- 
ditions almost impossible on the part of any one capable of distinguish- 
ing one disease from another. 

Prognosis. — The prognosis is unfavorable. Two cases of recovery 
are related by Duchenne, and other observers have reported improve- 
ments, but the tendency is to death, though life may be prolonged 
many years notwithstanding the gradual advance of the disease. And 
yet the fatal result is rarely directly due to the disease itself. Some 
intercurrent affection ensues, and the vital power, being enfeebled, 
cannot resist effectually the new disorder. Thus death occurred in 
my first case by pneumonia ; and of thirteen cases referred to by 
Poore, in which the termination is given, not one died directly of the 
disease. 

Morbid Anatomy and Pathology. — When the study of this affection 
was in its infancy, certain changes discovered in the spinal cord, and 
particularly in the cells of the anterior horns, were regarded as the 
primary lesions of this disease. Reports of cases in which autopsies 
were obtained byBarth, 1 Midler, 2 and Clark, 3 in earlier years, and even 
in later years by Gibney and Amidor., 4 seemed to confirm this view of 
the case ; but since then more careful investigation of the subject by 
Middleton 5 and Schultze, 6 and still more recently by Sachs, 7 shows 
almost conclusively that the primary pathological change occurs in the 
muscles, and that in the majority of instances the spinal cord is free 
from any semblance of disease. Sachs, 8 in his interesting paper on 
this subject, collected seventeen cases of this disease, in all of which 
scientific examinations of the cord were properly conducted. In eleven 
of these " the spinal cord and anterior nerve-roots were found abso- 
lutely normal" ; in the other six cases "the changes that were found 
could not be held responsible for the changes in the muscles." 

Handf ord 9 contributes another case, the study of which confirms 

1 " Beitrage zur Kenntiiiss der atrophia musculorum lipornatosa," Archiv der Heil- 
kunde, Leipzig, 1871, p. 120. 

2 "Beitrage zur path. Anat. und Physiol, des menschlichen Riickenmarks, Heft ii., 
Leipzig, 1870. 

3 Journal of Mental Sciences, April, 1870, p. 41. 

4 Transactions of the American Neurological Association, 1886. 

5 Glasgow Medical Journal, 18S4, No. 22, p. 81. 

6 " Leber den mit Hypertrophic yerbundenen progressiyen Muskelschvnmd," Wies- 
baden, 1886. 

7 Transactions of the Amei'ican Neurological Association, 1886. 

8 Rid. 

9 Transactions of the Pathological Society, London, 1888-89, xl., p. 24. 



638 DISEASES OF THE SPINAL CORD. 

the view, already expressed, of the myotic origin of the disease. The 
autopsy demonstrated the unusual extent to which the disease had 
advanced. In addition to the atrophy of the extremities, the muscles 
of the trunk were greatly affected. The pectoral muscles had disap- 
peared entirely, and the heart and diaphragm were both degenerated. 
Sections of the cord at all levels showed that the cells in the anterior 
horn were mainly in good condition, and seemed to be in their usual 
numbers. In most sections cells could be seen here and there pig- 
mented, or that did not stain well, or that had lost their processes, or 
in some way appeared degenerated. Such cells were, however, on the 
whole very few, and were not, in the author's opinion, sufficiently 
degenerated to account for such universal and extensive muscular 
degeneration. In the upper lumbar enlargement an area of softening 
was discovered situated in the gray substance of one lateral half, inter- 
mediate between the anterior and posterior horns. It seemed to be 
the result of a comparatively recent haemorrhage. 

It cannot be entertained for a moment that the area of softening 
was in any manner related to the symptoms of pseud o-hypertrophic 
paralysis. Its situation in one half of the cord and in the lumbar 
region, and the fact that it did not involve any of the multipolar cells, 
precludes the possibility of its affecting muscles, especially those sup- 
plied from regions of the cord above the seat of the softening. The 
slightly degenerated appearance of some of the cells in the anterior 
horn probably ensued because they were useless, the muscular fibres 
which they supplied having disappeared. 

The nerve-roots were healthy. 

Thus it would seem that the weight of evidence tends to prove 
that pseudo-hypertrophic paralysis is not a disease of the central 
nervous system. The majority of observers agree upon the morbid 
changes which occur in the muscles. In the first stage there may be 
— as Pepper has shown, as my second case likewise exhibits, and as 
occurred in Therese's 1 case — atrophy of the muscular fibres instead of 
hypertrophy. A microscopical examination shows the transverse striae 
to be in process of disappearing, and in some of the fibrillar to have 
altogether gone. 

The connective tissue already shows a tendency to proliferation, 
but there is as yet no trace of that fatty degeneration and deposit 
which afterward becomes the most striking patho-anatomical feature 
of the disease. In the case which I have detailed, a portion of the 
primarily-atrophied left rectus fern oris muscle was removed by Du- 
chenne's trocar, and, examined with a fourth-inch objective, presented 
the appearance above described. In Pepper's case not a single fibril 
of the deltoid muscle which he examined exhibited evidence of fatty 
degeneration, though the connective tissue was very greatly in excess 
1 France Med., Paris, 1889, i., p. 814. 



PSEUDO-IIYPERTROPHIC PARALYSIS. C39 

of the normal proportion, and in places there were small collections of 
minute fat-globules or refracting granules. 

But in the form in which hypertrophy is a prominent feature there 
may or may not be hypertrophy of the muscular fibres. Yirchow 
claims that hypertrophy of the muscular fibres is pathognomonic of the 
disease, but in JacobyV case there was a distinct diminution in the 
number of muscular fibres, some of which were small and some were 
normal, but none of them were hypertrophied. Middleton 2 noted 
variations in thickness of the muscular fibres. In some instances they 
appeared hypertrophied, in others they did not. All observers agree 
that there is a notably-increased development of the connective tissue, 
with fatty infiltration, and fatty degeneration of the muscular fibres. 

As the process advances, the fibrillse in great part disappear, fat 
and connective tissue crowding them out, as it were, and eventually 
even this latter is in a great measure replaced by fat-vesicles. The 
muscle is now at its most advanced stage of hypertrophy. But the 
process is not yet complete, for a stage of secondary atrophy begins, 
the fat is absorbed, and finally nothing is left but a few degenerated 
muscular fibrillar and a mass of connective tissue. 

There is thus in the first place simply a change in the muscular 
fibrillae characterized by a disappearance of the transverse striae. This 
is probably the first stage of the fatty degeneration, which is afterward 
manifested unmistakably. At the same time the connective tissue 
between the bundles of fibrillse and the fibrillae themselves is increased ' 
in amount. Then the disintegration of the muscular fibrillaB becomes 
more evident, the connective tissue is still more increased, and fat- 
vesicles make their appearance between the fibrillaB and the bundles of 
fibres. Finally, the muscular tissue mostly disappears, the fat is ab- 
sorbed, and connective tissue, with perhaps a few fibrillas, in a more or 
less advanced stage of degeneration, is all that remains. 

It is therefore evident, from what has been said, that pseudo-hyper- 
trophic paralysis is primarily a muscular dystrophy, beginning as an 
inflammation of the muscular tissue and connective tissue, and ending 
with a more or less complete degeneration. 

Treatment. — Duchenne, as we have seen, succeeded in curing two 
cases in their incipiency, with the faradaic current. Authors are agreed 
that, if anything is likely to prove successful, it is electricity in some 
one of its forms, and all cases have been treated with this agent. Thus 
far, however, not only is there no record of another cure, but there is 
scarcely the mention of even slight improvement. The disease has 
gone on slowly but certainly in its progress, unchecked by therapeuti- 
cal measures. 

Still we are not, on that account, to despair. I would recommend 
faradization and galvanization of the affected muscles, the application 
1 Journal of Nervous and Mental Diseases, 1887. 2 Op. tit. 



640 DISEASES OF THE SPINAL CORD. 

of heat, kneading the muscles, massage, and rest. Of these remedies 
I consider faradization the most important. It should be applied once 
or twice a day to all the implicated muscles. 

Internally, strychnia, iron, and phosphorus may be used, and bene- 
fit may be derived from their tonic virtues. 



This concludes what I have to say relative to the diseases of the 
spinal cord. I have endeavored to make the subject as plain as possi- 
ble, but, in the study of a class of diseases still to a great extent ob- 
scure in their medical relations, there must necessarily be defects in 
the description. 

In order to a better understanding of the normal and morbid anat- 
omy of the cord, as established by the most recent investigations, I 
have enlarged and modified from Flechsig and from Gowers a diagram 
of a transverse section, which will be found to give, on examination, 
very exact information. In it are clearly indicated the several divisions 
of the cord with the study of which we have been engaged. 




A. Anterior Median Fissure. 

B. Posterior Median Fissure. 

C. Intermediate Fissure. 

D. Anterior Gray Cornu. 

E. Posterior Gray Cornu. 

F. Gray Commissure, with Central Canal. 

G. Anterior Pyramidal Tract, or Uncrossed Pyramidal Tract, or Column of Ttirek. 
I. Anterior Root-Zones. 

K. Lateral Pyramidal Tract, or Crossed Pyramidal Tract. 

L. Direct Cerebellar Tract. 

M. Posterior External Column, or Column of Burdach. 

X. Posterior Median Column, or Column of Goll. 

P. Antero-Lateral Ascending Tract, or Column of Gowers. 



SECTION III. 
CEEEBBO-SPINAL DISEASES. 



CHAPTER I 

HYDROPHOBIA. 



Although there are objections to the name employed to designate 
the terrible disease I now propose to consider, the same is true of all 
other terms which have been applied to it, and the present has the ad- 
vantage of being well known. So long as we are obliged, through ig- 
norance of pathology and morbid anatomy, to use a nomenclature based 
on symptoms, we must expect to be inexact. The name hydrophobia 
is as old as Galen, and still retains its preeminence, notwithstanding 
the fact that the symptom on which it is based is sometimes absent. 

Symptoms. — Beginning with the reception of the injury by which 
the body has been inoculated, we find that it heals in the ordinary way, 
and that there are no immediate signs of infection. At a period which 
varies greatly in different cases, pain or a sensation of uneasiness is 
usually experienced at the seat of the wound. This, however, is rarely 
of such intensity as to cause suffering, and probably would generally 
be overlooked or disregarded but for the apprehension which the pa- 
tient has, and which directs his attention to every sensation which can 
be attributed to the wound. But there may be absolutely no pain or 
uneasiness other than such as are met with in all wounds till the phe- 
nomena of the affection are manifested. The period between the re- 
ception of the injury and the beginning of the symptoms of hydropho- 
bia is known as the stage of incubation. 

The duration of this stage is variable. It is rarely shorter than a 

month, and probably never longer than two years. Instances are on 

record, however, in which the disease has been developed within ten 

days, and others, about which, however, there is much doubt, in which 

the latent period has reached to ten years and longer. The vast ma- 
42 



642 CEREBRO-SPINAL DISEASES. 

jority of cases occur within seven months after the reception of the 
wound. In six cases which have been under my observation, the period 
of incubation varied from about twenty-five days to four months and a 
half. 

Dr. John Johnston, 1 however, refers to an opinion that in hot coun- 
tries the disease has appeared in four or .five days after the bite, and, on 
the margin of the page on which this statement is made, Dr. Hosack, 
to whom the book formerly belonged, has written a note, in which he 
states that it ensued in a child in New York five days after the bite 
was inflicted. 

During this period of incubation there are not often any indications 
of what is going to take place except in those cases in which there are 
abnormal sensations in the cicatrix or its neighborhood. Sometimes 
there are depression of spirits, anxiety, and derangement of the diges- 
tive functions, but these symptoms may fairly be attributed to the pe- 
culiar circumstances of the case, aside from any toxic influence due to 
infection. 

The first symptoms which appear are often directly connected with 
the cicatrix, which, if it has previously been free from abnormal appear- 
ances and sensations, now becomes subject to both. But there is no 
constancy even in these phenomena. They were altogether absent in 
one of my cases, and very slightly manifested in one other, if they were 
present at all. In this case, which I saw in consultation with Dr. S. G. 
Cook, 2 of this city, the patient, after other symptoms had appeared, oc- 
casionally clutched the place where he had been bitten, but denied, on 
being asked, that there was any pain at the spot. 

But, though there may be no symptoms of swelling, redness, or pain 
about the cicatrix, there are abnormal sensations in the nerves which 
radiate from it. Thus, if the injury has been in the leg, pains are felt- 
along the courses of the sciatic and crural nerves ; if in the hand, simi- 
lar sensations are experienced in the radial, ulnar, median, and other 
nerves of the upper extremity. Occasionally the pain is felt in the epi- 
gastric region, and in any situation is ordinarily accompanied by head- 
ache. At about the same time the respiration becomes sighing and 
irregular, there is a feeling of oppression or constriction in the chest, 
the pulse loses its force and uniformity, and there is an indefinable 
sense of anxiety. The sleep is scarcely ever natural. Either there is 
insomnia or drowsiness, and sleep, when obtained, is disturbed by fright- 
ful dreams, and is unrefreshing. The bowels are constipated, the skin 
is dry, and there are alternate chilis and flushes of heat. The duration 
of this stage is from two to four days. 

And then the period of full development begins ; characterized, at 
first, by an increase in the symptoms just mentioned, and subsequently 

1 "Cases of Lyssa, with Remarks," p. 5, in "Medical Essays," printed 1795 to 1805. 

2 " A Case of Hydrophobia," Journal of Psychological Medicine, January, 1870, p. 80. 



HYDKOPHOBIA. 643 

by the appearance of others not previously present. A peculiar sense 
of uneasiness is felt at the epigastrium, and a pain and constriction of 
the throat, which add greatly to the distress. The tongue becomes 
stiff and painful, and articulation is thereby rendered indistinct ; the 
respiration increases in irregularity, and becomes noisy and oppressed ; 
the rigidity of the muscles of the throat prevents or impedes degluti- 
tion, and the patient dreads attempting to swallow, from the experience 
he soon acquires that his efforts in this direction are attended with pain 
and spasm, which greatly increase his sufferings. Sometimes the con- 
vulsion of the pharyngeal muscles is so great that substances are thrown 
with great force out of the mouth. This was the case in three of the 
instances I witnessed. At the same time the spasm extends to other 
parts of the body, and occasionally becomes general. It is accompanied 
by pain in the epigastrium, and sometimes in the spine. Solids are 
swallowed with much more ease than liquids. Indeed, so great is the 
difference that the patient cannot even entertain the idea of swallow- 
ing any fluid, without being thrown into spasms. The sound of water 
splashing or trickling, the sight of it, the thought of it, and even an 
impression remotely connected with water, such as that produced by 
the reflection of rays of sunlight On the face by a mirror, will bring on 
a paroxysm of convulsions. With the spasm there are sobbings, trem- 
bling, and then a condition of exhaustion, during which the patient is 
bathed in perspiration. 

The following day the phenomena are still more strongly marked. 
The mouth is dry and parched, and yet the patient dare not attempt 
to quench his thirst ; vomiting ensues, the pulse becomes rapid and 
small, the pain in the pit of the stomach still increases, the headache is 
intense, and the countenance expresses terror, anxiety, and suffering. 
The pain in the spine augments and extends to the muscles of the neck 
and abdomen. The secretions of the mouth are altered, and the saliva 
is mixed with a frothy, tenacious mucus, which the patient is constant- 
ly attempting to eject, but which collects as fast as he can spit it out. 
The mouth and fauces are dry and painful, articulation is almost im- 
possible, and every attempt to relieve the distress by a few drops of 
water induces a return of the spasms and convulsions. Finally, every 
reflex excitation reaches the muscles of the throat ; the contact of the 
bedclothes, the jarring of the bed by persons walking in the room, the 
rustling of window-curtains — any thing capable of acting on the hear- 
ing, the eyesight, or the touch, may cause the spasms. 

As the disease advances, all the symptoms increase in violence, and 
still others make their appearance. The urine and faeces are often 
passed involuntarily, the skin becomes exquisitely sensitive, the body 
is in a constant state of agitation and tremor, alternating with spasms, 
and the tough, stringy, tenacious mucus collects in the throat and im* 
pedes respiration. 



644 CEREBRO-SPINAL DISEASES. 

Thus far the mental symptoms have scarcely been considered, but 
they are present almost from the first. Indeed, they may be among the 
very first indications of disorder. They consist of emotional disturb- 
ances of various kinds, and sometimes radical changes of character and 
disposition. 

It has been alleged by some authors that the dreams, at a very early 
period after inoculation, are connected with the animal giving the 
the wound. I have never met with this symptom, but in the case pre- 
viously cited, and which I saw twice in consultation, a circumstance 
still more remarkable is related by Dr. Cook. The patient, a child 
three years old, was bitten by a bitch in heat on or about August 20, 
1870. On November 15th the mother noticed that he slept badly ; on 
the 16th, among other manifestations, he " was cranky all day." On 
the 17th he was seen by Dr. Cook. 1 

" On entering the room," saj^s the doctor, in his report of the case, 
" and seeing several children, and not noticing any thing wrong with 
any of them, I very naturally inquired which was the patient. I was 
pointed to a little boy sitting at a table in a high chair. On approach- 
ing him, he turned his face toward me, revealing the most peculiar-look- 
ing eyes I have ever seen. They were not like those seen in persons 
suffering from delirium in prolonged fevers, nor }?et like those we see 
in the second stage of cerebral meningitis, although somewhat resem- 
bling both of these conditions, but more like the eyes of a person in a 
fit of violent anger, slightly combined with a feeling of fear. 

" When I reached out my hand to touch his, he shrank from me as 
from a blow, at the same time making a desperate effort to catch his 
breath, precisely as a naked person might if a pail of cold water was 
unexpectedly poured over him. This I understood to be a laryngeal 
spasm. It was very brief, lasting but the fraction of a minute, prob- 
ably not more than ten seconds. I took a seat a little distance from 
him, where I could see his every motion, and regarded him attentively 
for a long time. 

" He seemed an unusually intelligent child, for one of his age, speak- 
ing very distinctly with a clear, ringing voice, which his parents in- 
formed me was a little unnatural, as it * seemed strained.' He had at 
times a disposition to stammer, which was also unnatural. For one 
hour after my observation commenced, he talked almost incessantly of 
dogs, and repeated very few sentences a second time. He seemed 
familiar with all the most common breeds, relating some anecdote 
of the bull-dog, the mastiff, the bird-dog, the spaniel, the coach-dog, 
and the poodle. 

" Connected with all his naratives was a tragic or gloomy termina- 
tion. The mastiff, after carrying him an incredible distance about the 
city, finally disappeared through a bottomless hole in the street, he only 

1 Op. cit., p. 81. 



HYDROPHOBIA. 645 

escaping a similar fate by suddenly dismounting. The bull-dog, after 
bringing for his admiration and pleasure a great variety of puppies, sud- 
denly turned cannibal, and swallowed the whole lot. The spaniel, after 
having been his playmate for a very long time, finally took it into his 
head one day to get on to a coffin that was being carried through the 
streets, and ride away to reappear no more." 

There were no other evidences of disordered mental action in this 
child, and he died, perfectly conscious to the last. 

Usually, however, this is not the case, and various morbid desires 
are entertained by the patient. Thus, in a case which I saw in this 
city in 1865, there was an impulse to strike those near, and an intense 
dislike of certain persons who had always been intimate friends of the 
patient. In both the other cases there were paroxysms of previous 
delirium, during which the sufferers bit and struck at all within their 
reach, and of which hallucinations and delusions constituted marked 
features. In the case of the boy just cited, the stories of dogs which he 
related were evidently delusions which he accepted as realities. 

The temperature is always elevated from the very beginning of the 
disease. It is rarely below 105° Fahr., and may rise as high as 110° 
during the height of a paroxysm or immediately after its cessation. 

Death usually takes place on the third day after the accession of the 
symptoms indicating the full development of the disease. The chief of 
these is laryngeal spasm. A fatal termination is rarely delayed till 
after the third day, though cases are not uncommon in which it has en- 
sued on the first or second day. In all the cases, except two, which have 
been under my observation, the third was the fatal day. In Dr. Cook's 
the disease may be considered as having been fairly developed on the 
17th of November, the first day in which any spasm of the throat was 
witnessed. Death resulted on the evening of the 18th. 

In June, 1874, I attended, in consultation with Dr. "Alexander 
Hadden, my sixth case of hydrophobia. The patient, a man about 
twenty-five years of age, had been bitten about three weeks before by a 
dog not clearly identified. When Dr. Hadden first saw him on the 24th 
of June, at 8.30 p. m., the man. was in bed, complaining of nervousness, 
soreness in his neck and throat, and a strange feeling of tightness 
around the chest. His countenance was anxious, his pupils were di- 
lated, and his general appearance was that of a person facing some im- 
pending danger, and not in extreme pain. He said his throat was sore, 
and that he could not swallow any thing, not even water. Examination 
showed that there was no congestion or inflammation of his throat. 
His pulse, respiration, and temperature, were normal, excepting that he 
occasionally sighed. There was also a little disposition to hack and 
spit. He complained of thirst, but said he knew he could not drink, for 
the very sight of water made him shudder. He was told to try, and 
some water was brought, but the sight of it caused a violent spasm. He 



646 CEREBRO-SPIXAL DISEASES. 

threw himself around in the bed backward and forward, and ordered the 
water to be taken away. He immediately afterward called for the 
goblet, said he was thirsty and must drink, seized it, and with a violent 
effort succeeded in taking a single swallow, which was followed by a 
savere convulsive shudder and contraction of the muscles of the neck 
and chest. 

Dr. Hadden, recognizing the symptoms of hydrophobia, asked if he 
had been recently injured by any animal. At first he replied in the 
negative, but on the doctor's saying, " Not by a dog ? " he answered, 
" Only slightly on the knuckle of the right hand by a little black dog 
belonging to a baker around the corner on the avenue." He further 
stated that there was nothing the matter with the dog, for he had seen 
it afterward, and only about a week since it had been taken to the 
pound and the bite was inflicted three or four weeks before. 

For two days previously he had felt badly, was thirsty, and had 
drunk a good deal of water; and the evening before had gone out, but 
soon returned, saying he felt chilly. While taking a cup of tea at 6 p. m. 
that day (the 23d), he had experienced the first difficulty in swallowing. 
Shortly afterward, while going to the kitchen, a cool draught of air 
blew on him and caused him to stagger so that he nearly fell. 

The next morning Dr. Hadden saw him with Dr. Leavitt. 

"We found him in a frightful state of excitement; had broken 
down the bed, and was struggling with his attendants to get at liberty. 
He was shouting and crying out to them to let him go, and called for 
water, which, when brought, he could not drink. His mind was clear, 
and he knew all those around him; was spitting a viscid saliva, and was 
careful not to spit on any one, not even on his clothes. It was so 
abundant that his attendants were obliged to wipe it from his lips. Dr. 
Leavitt and myself, after viewing the case in all its aspects, concluded 
to inject in the tissue of the leg one-half a grain of morphine and one 
sixty-fourth of a grain of atropine in solution, which was done at 3 
A. m. by Dr. Leavitt. We carefully watched the effect till 3.30 A. m., 
when his violence having in no way abated, another injection was given 
in the same part, of three-eighths of a grain of morphine and one-eighth 
of a grain of atropine, which in some degree produced the character- 
istic effect of morphine, and very clearly the appearances of the atro- 
pine; for, notwithstanding he was struggling violently, the saliva, which 
had been very troublesome, was completely dried up, so much so that 
the patient himself remarked that he was very thirsty, and his mouth 
felt as if he had been chewing a brick. Fifteen drops of chloroform 
were then injected, with no effects whatever, unless to weaken his al- 
ready weak and frequent pulse. At 4.15 a. m., three-eighths of a grain 
of morphine were again introduced under the skin, without atropine. 
This quieted the patient so that he was easily restrained, and he re- 
mained in this condition from 4.30 A. m. till 10 a. m., when the effects 



HYDROPHOBIA. 647 

had so far passed off that the attendants were alarmed at his violence, 
and the abundance of saliva he was spitting from his mouth. Dr. Wil- 
liam A. Hammond saw him with me at this time. He supported the 
diagnosis and thought well of the treatment; he saw that it subdued vio- 
lence and suppressed the flow of saliva — the two most important feat- 
ures of this hopeless disease. At 10.15 A. m., by his order, three- 
eighths of a grain of morphia in solution were injected into the tissue 
of the thigh, which served to temper down the increasing violence of 
the spasms, but did not stop the flow of saliva. I accordingly, at 10.45 
A, m., injected three-eighths of a grain of morphia and one-fortieth of a 
grain of atropia, which had the desired effect of producing the quieting 
effect of the morphia as well as the specific effect of the atropia on the 
salivary glands. The poisonous effects of the morphia and atropia were 
at no time apparent. He died at 4.15 p. h., June 26, 1874, about twenty- 
four hours after the first spasm." * 

As stated by Dr. Hadden, I was called to see the patient at about 
ten o'clock on the morning of June 26th. When I went into the room 
he was lying upon the floor pinioned, to a certain extent, and surround- 
ed with pillows to prevent him injuring himself. He was then spitting 
continually ; in fact, every expiration was accompanied by an effort to 
spit out the thick, tenacious mucus so characteristic of hydrophobia. 
His pupils were largely dilated, but, as Dr. Hadden stated, not more 
so than before the atropia was given. He was able to converse with 
tolerable fluency, and, when I put two or three questions to him, he an- 
swered, but not very directly. So far as I could make out, both from 
his answers and appearance, he was not suffering from acute pain. 
There was a good deal of movement of his limbs, not apparently spas- 
modic, for there seemed to be the element of volition in the actions he 
made with his arms and legs. He could not swallow fluids, and even a 
piece of ice given to him was ejected with force from his throat. His 
pulse was too rapid to be counted, and his respiration was hurried and 
irregular. 

I fully concurred in the suggestion to give him morphia for the pur- 
pose of moderating the intensity of his symptoms. A hypodermic in- 
jection was administered, and a sedative effect was produced. After I 
left, his paroxysms returned with great violence, and he died that after- 
noon. 

Generally death occurs during a spasm. This was the result in four 
of the six cases I have witnessed. In the others the patients died 
quietly, a consequence probably of the sedative medicines administered. 
When death takes place during the former condition it is probably due 
to apncea ; in the latter, to exhaustion. In all cases the powers of life, 

1 " Report of a Case of Hydrophobia," by Alexander Hadden, M. D., " Proceedings 
of the New York Neurological Society," Psychological and Medico-Legal Journal, Sep- 
tember, 1874, p. 166. 



648 CEREBRO-SPINAL DISEASES. 

from the violent convulsions, the loss of sleep, and the deprivation of 
food, are drained away to their utmost. 

The most recent case of hydrophobia coming under my observation 
was that of a gentleman whom I saw at Haverstraw, New York, in 
consultation with Dr. W. B. Bailey, of that place, on May 25, 1887. 
The patient was bitten on the thumb by a small pet dog which had 
been bitten some time before by a strange cur. On a previous occasion 
the patient had found a bone lodged in the dog's throat, and, from the 
symptoms exhibited, thinking that something of this kind ailed the 
dog again, the owner put his hand down the animal's throat, and the 
thumb, coming in contact with one of the sharp teeth, was slightly cut. 
A short time afterward the dog died. Little was thought of the wound 
at the time ; but in a few days afterward the thumb became painful 
and began to swell, and Dr. Bailey cauterized the wound. The swell- 
ing gradually advanced up the arm, and became so painful that he was 
unable to sleep. All this subsided, however, until almost exactly a 
month subsequent to the infliction of the wound the first manifesta- 
tions of hydrophobia made their appearance. I saw him on the fourth 
day, about six o'clock in the evening, and he was then in bed sleeping 
quietly, under the influence of morphia. When he awoke he was per- 
fectly rational, shook hands with me, and talked quite cheerfully. He 
said he was feeling better, and, to try him, I asked him in an off-hand 
manner if he would like a drink of water. He answered " No," in a 
voice which showed great fear, and I noticed a twitching in the muscles 
of his throat that I had previously seen in hydrophobic patients. In 
order to satisfy myself completely in regard to the character of his 
disease, I told him that he would have to get up and take a drink. He 
replied that he would try, and I handed him a glass filled with water. 
As he took the tumbler in his hand he trembled violently from head 
to foot, and the muscles of his throat were again thrown into violent 
spasms. He made several unsuccessful attempts to raise the glass to 
his lips, but finally, with an almost superhuman effort, he succeeded. 
He managed to gulp down three swallows of the water, which caused 
such violent convulsions of the throat, and seemed to put him in so 
much agony, that I took it from him. He then got into bed and a 
hypodermic injection of morphia was given him and he sank into a 
peaceful slumber. Previous to my arrival he had had many severe 
spasms, but they had been quieted by morphia, and I advised that the 
administration, of this drug should be continued. He died the day 
after I saw him. 

Causes. — It has generally been supposed that hydrophobia has but 
one source in the human subject, and that is inoculation by the saliva 
of an animal affected with rabies ; that it cannot be communicated to 
one individual of the human species by the saliva of another affected 
with hydrophobia ; and that neither dogs nor other animals can be in- 



HYDROPHOBIA. 649 

fected by inoculation with the saliva of a hydrophobic man. Magen- 
die's experiment as to the latter point is considered by many to be of 
exceedingly doubtful value, as hydrophobia was, it is said, prevailing 
among dogs at the time, and that hence the animal may have been 
bitten. As we shall see hereafter, these suppositions are all more or 
less ill-founded. 

Thus it is very probable that the saliva of healthy animals, the dog 
especially, is, under certain circumstances, capable of producing hydro- 
phobia in man and other animals. A case of the kind is recorded in 
Huf eland's Journal of December, 1839, and similar ones are frequently 
met with. In none of the cases I have witnessed was the dog which 
had inflicted the wound supposed to have been rabid. In one case 
which I saw in this city, with a physician whose name I cannot recall, 
the patient, a stableman, was bitten by a dog that was to all appear- 
ance in perfect health. In the case reported by Dr. Cook, the animal, 
a bitch, was being led quietly through the passage-way of the house, 
when the child became entangled in the chain, fell against the dog, and 
was bitten apparently in anger. The animal was well known, and was 
not even suspected of being hydrophobic. She was in heat ; and Dr. 
Cook raises, for the first time to my knowledge, the question whether 
this circumstance renders the saliva of the animal capable of inducing 
hydrophobia in the human subject. With a view of throwing as much 
light as possible on the subject, he consulted the records of Bellevue 
Hospital, in order to ascertain the facts in relation to a man who died 
of what was supposed to be hydrophobia from the bite of a bitch in 
heat. The result of his inquiries was to show very certainly that the 
man did die of hydrophobia ; that the animal was not rabid, and that 
she was in heat. 

In the case, the details of which have just been given, there was a 
good deal of doubt in regard to the identification of the dog which in- 
flicted the bite. The patient said he had been bitten " by a little black 
dog belonging to a baker around the corner on the avenue." But no 
such dog was known, and there was no baker " around the corner," on 
either Second or Third Avenue. The only dog that was known to have 
bitten the man was alive and well on the 7th of July, two weeks after- 
ward. 

In the present state of our knowledge it is useless to pursue this 
point of the inquiry further. It is one in regard to which certainty 
appears to be impossible of attainment. Fleming, 2 however, seems 
to admit the possibility of an animal under strong sexual excite- 
ment being able to communicate hydrophobia to a healthy animal, 
when he says : 

1 " Dictionnaire des sciences medicales," article " Rage," tome xlvii., p. 46. Also 
Journal de physiologic, tome L, p. 47. 

2 " Rabies and Hydrophobia," London, 1872, p. 124. 



650 CEREBRO-SPINAL DISEASES. 

"The hypothesis that certain ferments — an improper term — may- 
be developed in great abundance in the saliva under the influence 
of psychical disturbance, would account for those instances in which 
rabies shows itself in dogs bitten by others which are excited or furious 
by sexual desire, though themselves healthy." 

It would appear from certain experiments that the saliva is the only 
means of communication. Thus Dupuytren, Breschet, and Magendie 
endeavored to convey the disease by injecting the blood of dogs suf- 
fering from rabies into the veins of healthy dogs, but always unsuc- 
cessfully. The flesh, milk, semen, and abdominal secretions were like- 
wise found not to be media for transmission. 

On the other hand, Eckel, of Vienna, after several failures, inocu- 
lated a dog with the blood of a man who was affected with hydropho- 
bia. On the sixty-second day thereafter the animal was seized with 
unmistakable rabies and died. Fleming, however, from whom I quote 
this statement, says that it must not be forgotten that, at the time of 
these experiments, rabies was raging as an epizootic. But Bouley, 1 
who has investigated the whole subject of hydrophobia with great abil- 
ity, declares that it can be transmitted only by inoculation, and the 
only agent which has the power of communicating it is the saliva, in 
which alone the virus exists. Any other liquid taken from a rabid ani- 
mal is ineffective. Inoculation by blood, even its transfusion, has failed 
to produce any results. He also says that all living beings affected 
with hydrophobia are capable of transmitting it ; that is, the saliva of 
all rabid animals is virulent, it matters not to what species they belong. 

Whether or not it originates spontaneously in the lower animals, it 
is very certain that it has no other origin in man than inoculation. 

Although there is no sure evidence on the point, there appears to 
be no room to doubt that hydrophobia may be communicated by inocu- 
lation from a person affected with the disease to an unaffected indi- 
vidual. Aurelianus, Enaux, and Chaussier, and others cited by Flem- 
ing, mention instances in which it has been induced in persons who 
have accidentally had the saliva of hydrophobic patients applied to 
their lips. Fleming 2 states that in 1871 a girl named Bence died in 
Liverpool from hydrophobia. It was believed she had not been bitten, 
but the death of her little brother, from the disease, occurred about 
three weeks previously, and the supposition was that the virus had 
been communicated in some way to the girl through a wound in 
her foot. 

The fact that hydrophobia can be communicated from man to the 
lower animals is sufficiently well established by the experiments of 
Magendie, Breschet, Earle, and Renault. 

1 " Hydrophobia," by H. Bouley, translated from the French by A. Liautaud, M. D., 
V.S., New York, 1874, p. 6. 

2 Op. cit., p. 141. 



HYDROPHOBIA. 651 

The wolf is said to be the most dangerous of all animals' when rabid, 
for the reason probably that it seizes the neck or face, parts not fully 
protected by clothing, and thus the saliva is not so apt to be rubbed off 
as when the leg, for instance, is the part attacked. 

The slightest abrasion of the skin coming in contact with the saliva 
may be sufficient for inoculation. Cases are recorded in which the dis- 
ease has resulted from dogs licking the hand or face on which there 
were pimples or sores. 

Diagnosis. — That protean disease, hysteria, occasionally puts on the 
semblance of hydrophobia. Several cases of the kind have occurred to 
me, and, in all, the symptoms were in general character very much like 
those which are exhibited by genuine hydrophobia, though in some re- 
spects, perhaps, a little exaggerated. It will in these and similar cases 
— the result of fright and imagination — often be found that the patient 
has been bitten by a dog not long before. There is a want of consist- 
ency about the symptoms which of itself is sufficient to excite suspicion 
as to the real character of the phenomena. Thus, although at times 
the attempt to swallow will excite laryngeal and other spasms, these do 
not always occur under similar circumstances, and are not induced by 
those secondary and more refined influences, such as the sound of fall- 
ing water, bright lights in the face, excitations applied to the skin, see- 
ing others drink, etc., which so generally cause them in the real dis- 
ease. There are not the same anxiety and depression in the simulated 
disease as in the real, though the apparent emotional disturbance is 
much greater. The hysterical patient is loud in the expression of ap- 
prehensions, while the real hydrophobic one, though intensely anxious 
and terrified, endeavors to prevent others perceiving the state of his mind. 

The history of the case, the existence of the hysterical diathesis, 
and the fact that the symptoms come on soon after the bite without any 
period of incubation, will further aid in establishing the diagnosis be- 
tween the false and the real disease. 

The last case of the simulated disease which has come under my ob- 
servation was that of a policeman whom I saw in consultation with Dr. 
S. G. Cook in the summer of 1874. The man was then in the Park 
Hospital, held down on a bed, and snapping like a dog at every person 
who came in his way. At the sight of water he became intensely ex- 
cited, foamed at the mouth, and went through a series of fearful con- 
tortions of his limbs. But, when I took a glass of water in my hand 
and told him in a commanding voice to drink immediately, he swallowed 
the liquid without the slightest difficulty. 

The bromide of potassium in large doses was prescribed, and the 
next day all his symptoms had disappeared. On inquiry it was 
ascertained that he had been bitten by a dog several days before, 
and that his comrades had frightened him by their inquiries and sug- 
gestions. 



652 CEREBRO-SPIXAL DISEASES. 

The fact "that a disease resembling hydrophobia may be induced by 
physical derangement and by mental disturbance especially of the im- 
agination, and that death may be the consequence, is very well estab- 
lished, and may account for the apparently spontaneous instances, and 
for those cases of long incubation which are cited by authors. 

Thus M. Labadie Lagrave 1 quotes from Raymond (de Marseille) the 
case of a child twelve years old who became hydrophobic without known 
cause and died at the end of ten days. Also a case from Rouppe of a 
sailor who had convulsions and died hydrophobic without known cause, 
and another from Pouteau of a man who died in fifteen hours with 
symptoms of hydrophobia which had ensued on a violent paroxysm of 
anger. 

Berthier 2 refers to several similar cases occurring as the result of 
menstrual derangement. 

Fleming 3 cites the instance of a woman who had been bitten in the 
face and who was admitted to the Hotel-Dieu in Paris. After a few 
days she was cured of her wounds and discharged. Going about her 
usual avocations one day she heard a man exclaim, " She has not gone 
mad, then ! " From that time she could not swallow liquids, and on the 
same day was readmitted to the Hotel-Dieu, and this time to die of 
hydrophobia. 

The following case is also given by Fleming: "A woman in the 
clinic of Dr. Maisonneuve had been bitten by a dog, which was supposed 
not to be rabid, and the injury had healed; when two months after the 
accident she was met by two students, who had been with the doctor at 
the time, and who asked her if she was not yet mad. Immediately she 
was seized with nervous symptoms, became intensely anxious and un- 
easy, and went into the hospital in the belief that she was hydrophobic. 
She was put under the care of M. Laugier and the following day was 
evidently affected with the disease; hemiplegia appeared, with a vio- 
lent delirium, accompanied by an irrepressible amount of fear, and she 
died asphyxiated in forty-eight hours." 

The temperature in all cases of pseudo-hydrophobia that I have wit- 
nessed was not above the normal standard. 

Hydrophobia has been confounded with tetanus, and some writers 
have regarded it as a modified form of this affection. The distinction 
is, however, so well marked that it scarcely seems necessary to dwell 
upon it. The facts that in tetanus the spasms are tonic, while in 
hydrophobia they are clonic ; that in the first-named they are mainly 
shown as regards the jaws and back, while in the latter they radiate 
from the throat ; that in tetanus the mind is clear throughout, while 

1 Article " Hydrophobic," in'^ouveau dictionnaire de medecine et de chirurgie pra- 
tiques," tome xviii., Paris, 1874, p. 17. 

8 "Des nevroses menstruelies," Paris, 1874, p. 169. 
3 Op. cit., p. 176. 



HYDROPHOBIA. 653 

in hydrophobia more or less mental implication is always present, 
will suffice to render any mistake in the diagnosis of the two diseases 
impossible. 

From epilepsy the distinction is so obvious as not to require further 
mention. 

Prognosis. — There is no authentic instance on record of a cure of 
hydrophobia. Several such have been reported, but inquiry has always 
shown misstatement or error somewhere. The fact that the hysterical 
counterpart has several times been regarded as the real disease, is 
the main support for the opinion of some authors that the affection is 
curable. 

Several years ago Dr. Ligget, 1 of Maryland, reported a case of Iry- 
drophobia cured by calomel. A careful examination of the details of 
this case excites very grave doubts in my mind in regard to its really 
being an instance of the disease in question. 

The subject was a negro-woman who had been bitten about two 
weeks before any symptoms were manifested. The dog was lying 
quietly in the yard, and bit her in the great-toe as she was teasing him 
with her foot. The animal was at once chained up, and died in two or 
three days with " all the symptoms of rabies canina in its most virulent 
form." It does not appear that the doctor saw the dog, and it is very 
probable that the rigid confinement would have caused the animal to 
exhibit symptoms which would easily be mistaken by laymen for those 
of hydrophobia. 

Again, the period of incubation was unusually short, and the symp- 
toms, as detailed by Dr. Ligget, are clearly not those of hydrophobia. 
Thus, although he repeatedly states that there was inability to swallow 
liquids, there is no distinct mention made of the pathognomonic laryn- 
geal and pharyngeal spasms which occur in hydrophobia, and which are 
so frightful in character. The convulsions all appear to have been gen- 
eral, and there was a " horror " of water, which is not a phenomenon of 
the true disease. For these reasons I am constrained to believe that 
the disease treated by drachm-doses of calomel was in reality one of hys- 
teria which assumed the form of hydrophobia. In this opinion I am 
sustained by an eminent medical gentleman residing in Dr. Ligget's 
neighborhood, who, as the latter admits, declared the affection to be 
"a case of that protean disease, hysteria, simulating hydrophobia." 
Calomel has been repeatedly tried before and since Dr. Ligget's case, 
but without effect. 

But, although the prognosis is so hopeless in the developed dis- 
ease, it is much more favorable as regards the probability of the 
supervention of hydrophobia from the bites of rabid animals ; for, of 

1 " Case of Hydrophobia successfully treated with Drachm-Doses of Calomel," Amer- 
ican Journal of Medical Science, January, 1860, p. 96. 



654 CEREBRO-SriNAL DISEASES. 

those bitten by dogs unmistakably affected with the disease, not more 
than one in fifteen becomes successfully inoculated. This liability 
differs greatly according to the circumstance of the part being cov- 
ered or not. The wounds of the face, neck, or hands, are much more 
likely to be followed by hydrophobia than those inflicted on the legs 
or feet, where the virus is rubbed off by the clothing before the teeth 
reach the flesh. 

The bite of a rabid wolf is more apt to be followed by the dis- 
ease than the bite of a dog, for the reason that the first-named gen- 
erally seizes the throat or face. Thus, Trolliet states that at Brives, 
in France, seventeen persons were bitten by a rabid wolf, of whom 
ten died of hydrophobia ; and, of twenty-three bitten by another, 
thirteen died. 

On the other hand, Hunter states that on one occasion a dog bit 
twenty persons, of whom only one was inoculated. Those first bitten 
by a rabid animal are more liable to have hydrophobia than those bit- 
ten subsequently, when the poison is in a measure exhausted. Proba- 
bly the most dangerous wounds are those which barely penetrate the 
epidermis, and in which, therefore, the venom is not washed away by 
any flow of blood. 

Morbid Anatomy. — Within the last few years the study of the mor- 
bid anatomy of hydrophobia has led to results which may be considered, 
at least for the present, as determining, with some degree of exactness, 
the situation and character of the essential lesions of this terrible dis- 
ease. 

In 1869 Meynert examined microscopically the spinal cords of a boy 
and girl, patients at Oppolzer's clinic, who died of hydrophobia. 

In the first case, he found thickening of the walls of the spinal ves- 
sels, amyloid degeneration and nuclear proliferation of the cells of the 
neuroglia. 

In the second case, the neuroglia of the posterior columns of the 
cord was hypertrophied, through swelling of the stellate bodies. In 
the antero-lateral columns there were granular and amyloid degenera- 
tion, and numerous distended blood-vessels. 

The cortical substance of the brain exhibited the presence of a large 
number of lacunae with colloid masses. The nerve-cells of this part 
were the seat partly of molecular disintegration, and partly of sclerotic 
enlargement. 

Next are the observations of Dr. Clifford Allbutt, 1 who examined 
the nerve-centres in two patients, who died of hydrophobia while in- 
mates of the Leeds General Infirmary. Throughout the brain and spinal 
cord there were evidences of great vascular congestion with transudation 
into the surrounding tissue. In several places the walls of the vessels 

1 "Specimens illustrating the Pathological Anatomy of Hydrophobia," "Transactions 
of the Pathological Society of London," vol. xxiii., p. 16, 1872. 



HYDROPHOBIA. 655 

were thickened and there were here and there patches of incipient 
nuclear proliferation. There were also haemorrhages into the medulla 
oblongata. In many places there was a refracting material to be seen 
outside of the vessels, which probably was of the nature of a coagulated 
fibrinous exudation. Finally, Dr. Allbutt found in the encephalon occa- 
sionally, and in both spinal cords, and especially in both medullas, little 
gaps caused by the disappearance of nerve-strands which had passed 
through the granular degeneration of Clarke. These phenomena, adds 
Dr. Allbutt, point to the action of an animal poison acting primarily 
on the cerebro-spinal nervous system. 

Then in July, 1874, were my own researches, 1 made at Dr. Hadden's 
request, in the case, the details of which, as observed during life, have 
just been given. 

As preliminary to the description of the microscopical appearances, 
it may be stated that, on removing the calvarium, the membranes of 
the brain were found to be congested, but there was no appearance of 
serous effusion to an abnormal extent either in the sub-arachnoidal 
space or in the ventricles. The substance of the brain was only slight- 
ly congested, but the consistence, especially of the cortical tissue, was 
somewhat less than normal. The cerebellum appeared to be healthy, 
as did also the pons Varolii, the corpus striatum, the optic thalamus, 
and other ganglia, with the exception of the medulla oblongata, which 
seemed to be slightly softened. The membranes covering it and the 
upper part of the spinal cord were congested. 

I took for examination (1) portions of the cortical substance of the 
brain ; (2) sections of the corpus striatum ; (3) sections of the optic 
thalamus ; (4) sections of the cerebellum ; (5) the pons Varolii ; (6) the 
medulla oblongata ; (7) a section of the spinal cord at the level of the 
second pair of cervical nerves ; (8) a portion of the pneumogastric 
nerve from the neck : 

1. Cortical substance of the brain. 

My examinations of this tissue were made upon specimens which 
had been kept in absolute alcohol eighteen hours, in glass tubes sur- 
rounded with ice. I experienced no difficulty in cutting sufficiently 
thin sections. In all the sections the following conditions existed (ob- 
ject-glass one-fourth inch) : 

a. The blood-vessels were increased in size and number, and their 
walls appeared to be thickened. 

b. There were minute extravasations of blood throughout, in some 
of which the blood-disks could still be distinguished, but in most of 
them they were broken down. 

e. The external layer of nerve-cells had almost entirely been re- 
placed by fatty matter in the form of oil-globules. The cells that re- 

1 "Proceedings of the New York Neurological Society," July 7, 1874, in Psychological 
and Medico-LegalJournal, September, 1874, p. 169. 



656 



CEREBROSPINAL DISEASES. 



mained were filled with a highly-refracting granular material, which 
was also oil in very minute particles. None of these cells were bi-nu- 
clear. Amyloid corpuscles were discovered generally at the junction 
of this with the next stratum. 

d. The second layer of cells had also to a great degree been re- 
placed by fat, but not to the same extent as the outer layer. It is 
well known that this layer is composed of more numerous and larger 
cells than the outer ; but there was no doubt of their atrophy or dis- 
appearance. 

e. The third layer, composed of large cells, was scarcely affected. A 
few oil-globules were seen, and occasionally an amyloid corpuscle. 
The remaining strata were not involved, so far as I could see, to the 
slighest extent. 

In Fig. 98 a vertical section of the cortical substance is seen: 1, the 




outer or peripheral stratum ; 2, the second layer ; 3, the third layer or 
large cells. 

2. The corpus striatum, the optic thalamus, and the cerebellum were 
in an apparently normal condition, though there was some evidence of 
arterial injection. 

3. The pons Varolii was not examined in the fresh state, but was 
placed entire in a solution of bichromate of potash to harden. Subse- 
quently examined, it was found to be the seat of extravasation of 
blood, and the vessels were enlarged and their walls thickened. 

4. The greater portion of the medulla oblongata was also placed in 



HYDROPHOBIA. 657 

the bichromate of potash solution, but several sections were made after 
the part had been in absolute alcohol surrounded by ice for twenty- 
four hours. 

a. The first of these was made through the olivary bodies, at the 
level of the floor of the fourth ventricle, so as to include the nuclei of 
the pneumogastric and hypoglossal nerves. 

Numerous extravasations of blood could be seen with the naked eye, 
but with an inch objective they were more clearly made out. The ves- 
sels were then seen to be enlarged and more numerous than in the nor- 
mal condition. The gray matter forming the nuclei of the pneumogas- 
tric and hypoglossal nerves was observed to be of a distinctly granular 
appearance, and the roots of the nerves presented a like characteristic. 
In other respects the section exhibited nothing abnormal. 

b. Examined with a fourth-inch objective, this granular matter of 
the nuclei was seen to consist of oil-globules and amyloid corpuscles. 
The cells were ascertained to be atrophied both in size and numbers. 
Indeed, they had almost entirely disappeared. Of course it was not pos- 
sible, in a fresh and unprepared preparation, to form any definite idea 
of the relative proportion of nerve to neuroglia cells, but the deficiency 
of all cell-structure was very remarkable. (Fig. 99, a, oil-globules ; 
b, amyloid bodies ; c, nerve-cells ; d, blood-vessels.) 

Fig. 100. 

ai - KWK3 

Fig. 99. 

1 




%Ms 



c. The nerve-roots, when examined in like manner, were seen to 
have undergone a similar change, the granular matter consisting en- 
tirely of fat, mainly in the form of oil-globules (Fig. 100). 
43 



658 



CEREBRO-SPINAL DISEASES. 



Sections made immediately below the level of the point of the 
calamus scriptorius, so as to include the main root of the spinal ac- 
cessory nerve and its nucleus, exhibited almost exactly the same 
appearances. 

5. The Spinal Cord. — The section of the cord was made at a point 
about midway between the first and second cervical nerves. The gray 
matter of the anterior and posterior horns was found in a state of granu- 
lar and fatty degeneration, the cells atrophied, and the nerve-roots in 

Fig. 101. 




a similar condition. In the white matter, both of the anterior and 
posterior columns, there was nuclear proliferation of the neuroglia- 
cells (Fig. 101). 

6. The peripheral portion of the pneumogastric nerve, carefully 
removed by my assistant and placed in strong alcohol, exhibited a red 
appearance, but this may have been due to imbibition. 

Benedict, 1 about the time of my own observations, made a series 
of researches into the morbid anatomy of hydrophobia as met with in 
dogs. His results were — 

1. The vessels situated between the cerebral convolutions were 
distended with blood, and their external walls were coated with 
an exudation of a highly refractive material consisting of granules. 

2. Numerous cavities were found to exist in the gray matter of the 
brain, and these were filled with a like granular, highly refracting ma- 
terial similar to that found in the walls of the vessels. s 

1 " Die anatomischen Veranderungen bei der Lyssa des Hundes," Wiener medieinische 
Presse, July 5, 1874. 



HYDROPHOBIA. 659 

3. Masses of myeline, indicative of softening, and chemical changes 
of the nerve-tissue, were also discovered. 

Benedict regards the appearances as identical with those which 
Lockhart Clarke has considered as indicating granular degeneration. 

From the foregoing data it will be perceived that at last something 
definite has been ascertained relative to the morbid anatomy of hydro- 
phobia. Whether we regard the condition, according to Benedict, as an 
acute exudative inflammation, or as a granular degeneration, is of no con- 
sequence so far as the facts are concerned. Whether on the one hand 
the granular matter is an exudation, or whether it results from degenera- 
tion of the nerve-tissue, are points which will probably ere long be 
cleared up. My own view is in accordance with that of Lockhart Clarke, 
who, detecting a like change in other affections of the nerve-centres, 
views it not as an exudation but as a degeneration. 

As to the gross lesions, congestion of the brain and spinal cord has 
been found by many observers. 

Sometimes . the nerves at the wound are inflamed, but this is not a 
uniform occurrence. The eighth pair has been found to present a pink- 
ish appearance in some cases. In four cases in which the blood was 
examined by Schivardi, 1 infusoria of the genera bacterium, monas, 
vibrio, and torula, existed. 

The fauces, pharynx, larynx, trachea, and lungs, are generally found 
reddened and congested, as much from the asphyxia as from any spe- 
cific influence of the disease. 

Pathology. — Even if we had no information relative to the morbid 
anatomy of hydrophobia, no one who has ever witnessed a case could 
fail to perceive the implication of the hemispheres, the medulla oblon- 
gata, and the spinal cord. The hallucinations and other mental phe- 
nomena point to the hemispheres ; the irregular action of the respira- 
tory muscles and the heart, together with the gastric derangement and 
pharyngeal convulsions, indicates the implication of the pneumogastric 
nerves ; and the spasms of the larynx point to the origins of the spinal 
accessory nerves in the spinal cord. Since we have arrived at some 
degree of exactness relative to the lesions in the disease, we cannot 
fail to have our conviction on these points strengthened. 

The nature of the virus is unknown. It is probably of the nature 
of a ferment, but this cannot be regarded as satisfactorily proved. 

In 1820, Dr. Marochetti observed, in the Ukraine, that during the 
formative period of hydrophobia small vesicles or pustules formed un- 
der the tongue, and that, if these were opened and cauterized, the fur- 
ther development of the disease was prevented. I have -never been 
able to find these formations, but they were recognized, two years after 
Marochetti published his account, by Magistral, in France. This latter 
opened and cauterized them in the manner recommended by Marochetti 

1 " Observations nouvelles sur la rage," Besancon, 1868. p. 22. 



660 CEREBRO-SPINAL DISEASES. 

in ten cases, in five of which, nevertheless, the affection went on to 
full development, and the patients died. I am not aware that any one 
else has discovered these pustules. 

For full details relative to hydrophobia as it appears in dogs, I 
must refer the reader to the late Mr. Youatt's excellent book on canine 
madness, and to the more recent and thorough treatise of Fleming. I 
may state that it is very clearly established that canine rabies is not 
so frequent in very hot as it is in temperate or cold weather ; that it 
is not, induced by thirst or improper food, or by preventing copulation. 

Is hydrophobia primarily a disease of the nerve-centres or a blood- 
disease ? I suppose it is utterly impossible, in the present state of our 
knowledge, to answer such a question. It may start as a blood-disease 
and end as a nerve-disease. Blood-diseases lead to structural changes 
of various organs of the body, and the nerve-centres are likewise in- 
volved to a considerable extent. Is it not worth while to call attention 
to the numerous instances of blood-diseases which produce structural 
changes ? Hydrophobia may be a blood-disease, and yet afterward 
be succeeded by changes in the nerve-centres. It is not necessary to 
suppose that hydrophobia is a nerve-disease from the beginning. It is 
perfectly possible, however, that it may be, and there are a great many 
instances which can readily be adduced in proof of this assertion. 
Take tetanus for example. Very few pathologists pretend to say that 
tetanus is a blood-disease. It is a disease propagated through the 
nerve-tissue starting from injury of a peripheral nerve, and inducing 
structural changes in the spinal cord. Dr. Lockhart Clarke, as we have 
seen, has ascertained in a number of cases that the essential condition 
of tetanus is a granular degeneration of the cord, and that is, probably, 
only the beginning of the fatty degeneration I find in hydrophobia, 
and yet there is no suspicion of blood-poisoning in tetanus. Hydro- 
phobia presents many analogies to tetanus, not only in its morbid anat- 
omy but in its natural history. 

Epilepsy can be caused by injuries to peripheral nerves. I had a 
case some years ago of a lady who wounded her thumb, and six months 
afterward she had epileptic paroxysms, which were preceded by an aura 
originating in the cicatrix. And if epilepsy — which is another one of 
the spasmodic diseases — can be induced by a simple wound, why not 
hydrophobia ? So that we have examples of analogous diseases caused 
by wounds of nerves, without the necessity of supposing the blood to 
be primarily affected. 

Still, there cannot be much doubt that the poison in the saliva, and 
not the wound made by the animal's teeth, is the essential influence 
producing hydrophobia. It is not at all certain, however, that the lat- 
ter may not in some cases produce a modification of the characteristics 
of the disease, perhaps causing those tetanoid phenomena which are oc- 
casionally present. 



HYDROPHOBIA. 661 

Treatment. — The measures of treatment relate to those proper im- 
mediately after the infliction of the wound, with the view of preventing 
the development of the disease, and those advisable after the affection 
is unmistakably manifested. 

Under the first category comes excision, which should be performed 
as soon as possible, and which is probably the best of all prophylactics. 
The operation should not be done with a niggardly hand, but every part 
with which the teeth of the animal have come in contact should be re- 
moved, as well as the tissue into which the poison may have become 
infiltrated. Previous to the operation, in fact as soon as the wound 
has been received, a tight ligature should be bound around the limb 
immediately above the injury, and, after the knife has done its work, 
cupping-glasses should be applied over the spot, till the tissiies in the 
vicinity are thoroughly drained of blood. I have performed excision, 
for the wounds received from dogs certainly rabid, eleven times, and 
always with the effect of preventing hydrophobia. 

Cauterization may be performed instead of excision, and is preferred 
by some practitioners. Mr. Youatt used it with over four hundred per- 
sons bitten by rabid animals, and never unsuccessfully. Four times he 
employed it on himself, but there is a strong probability that the prac- 
tice at last failed with Mr. Youatt himself, for he committed suicide 
while supposed to be suffering from the initial symptoms of hydropho- 
bia. 

He preferred the nitrate of silver as an escharotic. Others have 
made use of the actual cautery, caustic alkalies, the mineral acids, 
arsenic, chloride of zinc, and carbolic acid. I have employed cauteriza- 
tion seven times — four with the nitrate of silver and three with the 
actual cautery — upon persons bitten by rabid dogs, and always with 
success. 

Mr. Youatt at one time had faith that the Scutellaria lateriflora, or 
scullcap, was a preventive. He moistened three pieces of tape with 
the saliva of a rabid dog, and inserted them as rowels into the skin of 
three dogs. To two of these he gave Scutellaria combined with bella- 
donna, while the third was left to itself. On the twenty-ninth day 
after the inoculation this latter became rabid, while the others, several 
months afterward, were alive and well. 

Notwithstanding this experience, it would not be justifiable in the 
physician to neglect performing either excision or cauterization as soon 
as possible after the reception of the bite. Even if several weeks or 
months have elapsed, one or the other — preferably excision — should be 
performed. 

The researches of Pasteur relative to the production and prevention 
of hydrophobia have not yet, in my opinion, led to any definite results. 
It would appear, from accounts that have reached us from France, that 
many persons inoculated after Pasteur's method have subsequently 



662 CEREBROSPINAL DISEASES. 

died of hydrophobia, while it is very certain that many who have been 
inoculated in Pasteur's Institute in Paris had not previously been 
bitten by rabid animals. In this country such statistics as have been 
published are to the like effect. 1 It would certainly, therefore, be pre- 
mature, in the present state of our knowledge, to give an adhesion to 
the Pasteur method. On the contrary, after due consideration, I am 
inclined to express the opinion that it is not so sure a preventive of 
hydrophobia as is early excision or cauterization. Were I myself so 
unfortunate as to be bitten by a hydrophobic animal, I would not sub- 
ject myself to inoculation after the process in question. 

As to the treatment of the fully-developed disease, there is noth- 
ing, in my opinion, which has hitherto succeeded in arresting its 
onward course. Cases of cure have been reported, but, as already 
stated, they are open to the suspicion of not being true instances of 
the disease. 

Excessive bloodletting has been reported as a successful remedy ; 
injection of warm water into the veins dissipated the paroxysms in a case 
reported by Magendie, the patient, however, dying ; and nearly every 
stimulant, narcotic and sedative, in the materia medica has been used. 
In the case which I saw with Dr. Cook, and which has already been 
cited, the hydrate of chloral was administered. The effect certainly 
was to mitigate the severity and frequency of the spasms, but it was, 
as Dr. Cook states, given too late in the course of the disease to pro- 
duce any permanently curative result. In the present state of our 
knowledge I should be more disposed to rely on the hot-air bath at a 
temperature of about 200° Fahr., and the administration of hydrate of 
chloral in large doses frequently repeated, than on any other plan 
of treatment. In Dr. Cook's case the Turkish bath was proposed, but 
the parents of the child would not consent to its use. Hypodermic 
injections of morphia and atropia may be used with some advantage 
to mitigate the force of the paroxysms. 

Before concluding my remarks on hydrophobia, it is proper to 
allude to the attempts of Dr. Schivardi, 2 of Milan, to cure the disease 
by the primary galvanic current. In one case the current was feeble, 
and was continued for nineteen hours. Great improvement ensued ; 
the oppression disappeared, and the dysphagia was entirely relieved. 
Through some misunderstanding, advantage was not taken of these 
ameliorations, and the patient was allowed to die. 

In the other case, which was one of undoubted hydrophobia, oc- 
curring in a girl nine years old, the current from twenty-two Daniell's 
cells was employed. The current was passed from the soles of the 
feet to the forehead for fifty-eight hours almost continuously, and the 
duration of the disease prolonged to seven days and seven hours, when 

1 See Medical and Surgical Reporter, July 5 and October 25, 1890. 

2 " Observations nouvelles sur la rage." 



EPILEPSY. 663 

the patient died. During the last two days there were no hydrophobic 
symptoms. 

Further trials are necessary before the therapeutical value of gal- 
vanism in hydrophobia can be ascertained. 



CHAPTER II. 

EPILEPSY. 



Epilepsy, although only a symptom of a morbid condition, must for 
the present be considered as a disease, for the reason that we are not 
able to designate with certainty its exact seat, or the nature of the 
lesion which exists. It is characterized by paroxysms of more or less 
frequency and severity, during which consciousness is lost, and which 
may or may not be marked by slight spasm, or partial or general con- 
vulsions, or mental aberration, or by all of these circumstances collec- 
tively. The essential element of the epileptic paroxysm is loss of con- 
sciousness. Without that there is no true, fully -formed epileptic par- 
oxysm. 

Symptoms. — Although in many cases there are no precursory phe- 
nomena, it often happens that there are indications of an approaching 
attack. These are exceedingly variable in character and situation. 
They may consist of pain in the head, a sensation of constriction or 
fullness, vertigo, noises in the ears, a feeling as if the ears are stopped 
with cotton or water, flashes of light, or sudden blindness, illusions or 
hallucinations of any of the senses — irritability of temper, extraordinary 
cheerfulness, difficulties of speech, pains in various parts of the body, 
especially in the stomach, bowels, or ovaries, sensations of numbness 
or of tingling, or of an indescribable character, which begin in an ex- 
tremity or in some other region, and appear to pass rapidly to the head 
— a feeling of constriction in the throat, vomiting, sudden evacuation of 
the bladder or rectum, erections of the penis, with or without the sexual 
orgasm, and discharge of semen, with many others of almost every pos- 
sible description. 

The prodromata may precede the attack by a considerable period, 
but usually are only a few moments in advance of it. Indeed, often 
the interval is so short that they may be regarded as a part of the 
paroxysm. 

The sensations of numbness or tingling, or of an electric shock, as a 
sharp stab, or blow, or pain, which precede the attack and which origi- 
nate in different parts of the body, and in some cases seem to run rap- 
idly toward the head, are called auras. Sometimes this aura is fixed, 
and may consist of various derangements of sensation besides those above 



604 CEREBROSPINAL DISEASES. 

mentioned. In a number of my patients it has been a sensation at the 
pit of the stomach, such as that produced by a slight feeling of hunger 
or of anxiety. Again, it has consisted of a sharp impression on the 
tongue; at others of a subjective sense of smell, and again colored 
visions, or hallucinations of sight. 

In regard to these aurae of colors, Dr. Hughlings Jackson * has made 
some interesting observations. He finds that red is the color which is 
usually seen first, though the others may follow in such rapid succession 
as to present an image of all the primary colors. Loss of the power to 
see colors (color-blindness) is generally first shown as regards red; and 
if this affection advances, the insensibility is progressively shown tow- 
ard the violet end of the spectrum. So in the epileptic chromatic 
hyperesthesia, the formation of colors is in the same direction, and 
hence red is first perceived and violet last — theoretically, at least, for 
there are not yet sufficient data collected to enable us to speak with 
any degree of certainty on the subject. There are exceptions, how- 
ever, for Dr. Jackson cites the case of one of his patients who always 
saw blue just before an attack. In my own experience, red has been 
invariably the predominating color, and in most cases the only one. 
The case of the gentleman who, just before his paroxysm of epilepsy, 
saw an old woman clothed in red approach him, with a stick raised in a 
threatening manner, and the fit coming on as soon as the blow fell on 
his head, is well known. Two similar instances" have come under my 
own notice. 

Other derangements of sight may coexist with the chiomatism as 
epileptic aura?. Thus, Sauvages 3 mentions the fact that a woman sub- 
ject to epilepsy saw during the paroxysm dreadful spectres, and that 
real objects appeared magnified to an extraordinary degree; a fly 
seemed as large as a fowl, and a fowl appeared equal in size to an ox. 
In colored objects, green predominated with her, a fact which Ferrier 
states he has met with in other convulsive diseases. He also states 
that a very intelligent boy, who was under his care for convulsions of 
the voluntary muscles, when he looked at some large caricatures, glar- 
ingly colored with red and yellow, insisted on it that they were covered 
with green, till his paroxysm abated, " during which his intellects had 
not been at all affected." 

A young lady, who had overtasked her mind at school, was thrown 
thereby into what I regarded as a more or less hysterical condition, but 
which some authorities would probably consider epileptic. She saw 
spectres of various kinds all day, but every real object at which she 
looked appeared to be of an enormous size: a head, for instance, seemed 
to be several feet in diameter, and little children looked like giants. 

1 British Medical Journal, February 7, 1874. 

2 Reported by Ferrier, in "An Essay toward a Theory of Apparitions," London, 1813, 
p. 86. 



EPILEPSY. . 665 

When I took out my watch, while examining her pulse, she remarked 
that it was as large as the wheel of a carriage. 

In the case of a young gentleman, now under my care for epilepsy, 
the attacks are invariably preceded by a period which lasts several 
hours and sometimes a whole day, during which he "sees small." 
Every thing appears to be of infinitesimal size. This phenomenon I have 
never seen noted by any other writer on epilepsy. 

Auras connected with the sense of hearing are uncommon, except 
such as merely consist of tinnitus — roaring, buzzing, singing, etc. — 
these are often met with. But in one case there were distinct hallu- 
cinations of hearing preceding the attack, the patient always fancying 
that he heard his name repeatedly called. 

An aura may be entirely manifested by dreams or delusions. As an 
instance of the first I quote the following remarkable case from my trea- 
tise on " Sleep and its Derangements." The patient occasionally visits 
me for medical advice, but has had no epileptic paroxysm for over four 
years. 

" A lady of decided good sense had an epileptic seizure, w ; hich was 
preceded by a singular dream. She had gone to bed feeling somewhat 
fatigued with the labors of the day, which had consisted in attending 
three or four morning receptions, winding up with a dinner-party. She 
had scarcely fallen asleep when she dreamed that an old man clothed 
in black approached her, holding an iron crown of great weight in his 
hands. As he came nearer she perceived that it was her father, who had 
been dead several years, but whose features she distinctly recollected. 
Holding the crown at arm's length, he said: * My daughter, daring my life- 
time I was forced to wear this crown; death relieved me of the burden, 
but it now descends to you.' Saying which, he placed the crown on 
her head and disappeared gradually from her sight. Immediately she 
felt a great weight and an intense feeling of constriction in her head. 
To add to her distress she imagined that the rim of the crown was stud- 
ded on the inside with sharp points which wounded her forehead so that 
the blood streamed down her face. She awoke with agitation, excited, 
but felt nothing uncomfortable. Looking at the clock on the mantel- 
piece, she found that she had been in bed exactly thirty-five minutes. 
She returned to bed and soon fell asleep, but was again awakened by a 
similar dream. This time the apparition reproached her for not being 
willing to wear the crown. She had been in bed this last time over 
three hours before awakening. Again she fell asleep, and again, at 
broad daylight, was awakened by a like dream. 

" She now got up, took a bath, and proceeded to dress herself, witft 
her maid's assistance. Recalling the particulars of her dream, she rec- 
ollected that she had heard her father say one day that in his youth, 
while in England, his native country, he had been subject to epileptic 
convulsions, consequent on a fall from a tree, and that he had been 



GG6 • CEREBROSPINAL DISEASES. 

cured by having the operation of trephining performed by a distin- 
guished London surgeon. 

"Though by no means superstitious, the dreams made a deep im- 
pression upon her, and, her sister entering the room at the time, she 
proceeded to detail them to her. While thus engaged she suddenly 
gave a loud scream, became unconscious, and fell upon the floor, in a 
true epileptic convulsion. This paroxysm was not a very severe one. 
It was followed in about a week by another, and, strange to say, this 
was preceded as the first by a dream of her father placing an iron crown 
on her head, and of pain being thereby produced." 

Subsequently this lady had two other attacks, at intervals of several 
months, and both were preceded by the dream of the iron crown. 

In the case of a gentleman formerly under my treatment for epi- 
lepsy, the fits were invariably preceded by dreams of troubles of the 
head, such as decapitation, hanging, perforation with an auger, etc. 

It is probable that in such cases as the foregoing, the dream is ex- 
cited, as dreams often are, by derangements of sensibility, which are 
themselves the aurae. 

In some cases the aurae are entirely psychical, consisting of illusions, 
hallucinations, or delusions. Delusions are not common as aurae. I 
have, however, had one case in a lady, who had an epileptic seizure 
immediately after hearing of the death of a gentleman to whom she was 
engaged to be married, and whose subsequent paroxysms were almost 
always preceded by the delusion that she was going to be killed. There 
was no exaggeration of motility, but the delusion was firmly held and 
acted upon, to the extent that she would give away her effects, and 
make other preparations for her death. The following day the fit 
usually occurred, although sometimes it was delayed for two days. 

Delasiauve, 1 of two hundred and sixty-four cases, found the parox- 
ysms unannounced in one hundred and one, and with precursory phe- 
nomena in one hundred and eighty-three. The prodromata were im- 
mediate in one hundred and fifty cases. These he divides into seven 
categories, as follows. It is to be recollected that cases may appear un- 
der one or more categories, according as the prodromata, as is often the 
case, are met with simultaneously in different parts of the body : 

First Series. — Precursory Signs in the Head. — Seventy-five cases. 

Vertigo, flashes of light 33 

Headache, weight in the head 15 

Heat of face 3 

Various localized sensations 13 

Indefinite sensations 1 

Illusions, hallucinations, and other sensorial aberrations 9 

Rotation of the head or of the eyes 5 

Grinding of the teeth, derangement of the motility of the tongue 2 

Tendency to sleep 1 

Constriction of the throat 3 

1 " Traite de l'epilepsie — histoire — traitement — medecine legale," Paris, 1854, p. 47. 



EPILEPSY. ^67 

Second Skkies. — Precursory Signs in the Throat. — Twenty-two 
cases. 

Oppression of the chest and sense of suffocation 9 

Sensation of a ball or of motion in the pectoral region 2 

Shivering sensation of cold or of an aura 5 

Pain or heat 4 

Palpitations, spasms 2 

Third Seeies. — Precursory Signs in the Abdomen. — Thirty-two 
cases. 

Pain with or without oppression, eructations, vomiting 13 

Intestinal or uterine colic 3 

Sensation of a ball 3 

Sensation of cold, of a vapor, etc 6 

Stomachal heat , 1 

Undefinable sensations 6 

Fourth Series. — Precursory Signs in the Extremities. — Ninety 
four cases. 

Numbness, contractions, jerkings, retractions, cramps, formications, etc. . 36 

Pain with or without spasms 13 

Tremblings 10 

Aura or phenomena approaching thereto 20 

Undefinable sensations 15 

Fifth Series. — Precursory Signs, consisting of General and Un- 
definable Sensations. — Twenty-two cases. 

General agitation or rotation of the body 8 

Condition of discomfort, fainting, etc 6 

Vague sensations 1 

Moroseness 1 

Sixth Series. — Precursory Signs situated in the Genital Organs. 
— Five cases, such as retraction of the testicles, aura starting from the 
testicles and spermatic cords, sensations located in the uterus, etc. 

Seventh Series. — Exceptional Gases. — Desire to defecate, to uri- 
nate, profuse perspiration, etc. 

The Paroxysm. — Great differences are observed in the character 
and severity of the paroxysm. Ordinarily two varieties are recognized, 
the petit mal or slight attack, and the grand mal or severe seizure. 
The first is unattended by marked spasm or agitation ; the latter is 
characterized by more or less violent tonic and clonic convulsions. 
These divisions are, however, not regarded as sufficiently precise by 
those who have studied the disease in question with care and precision, 
and more minute classifications of the phenomena of the epileptic par- 
oxysm have accordingly been made. The one which I have used in my 
lectures at the University Medical College for several years past is less 



668 CEkEBRO-SPINAL DISEASES. 

complex than some others, and embraces all the known varieties. It 
is as follows : 

1. Momentary unconsciousness without marked spasm. 

2. Unconsciousness with evident though local spasm. 

3. Unconsciousness with general tonic and clonic convulsions. 

4. Irregular or aborted paroxysms. 

5. Recent investigations have led me to the recognition of a dis- 
tinct form of epilepsy characterized by hallucinations, and to which I 
have ventured to propose the name Thalamic Epilepsy. 

Besides these several varieties, there are certain accompaniments, 
such as hysteria, mania, and paralysis, which will require consideration. 

1. Momentary Unconsciousness without Evident Spasm. — The pa- 
tient is perhaps standing, engaged in conversation, when a momentary 
blank in his mental processes occurs. It probably does not attract 
attention ; it is instantaneous, disappears, leaving no feeling of dis- 
comfort after it, and there is an almost immediate continuance of his 
thoughts and speech. Or he may be walking in the street when the 
accession occurs. He loses himself for an instant, but he continues to 
walk, and does not even stagger. 

In somewhat more severe seizures, if conversing, he stops sudden- 
ly, stares vacantly but fixedly for a moment, and may drop anything 
which he has in his hand. 

If walking, his steps are arrested for an instant, he staggers, and 
would fall but for the quick return of consciousness. 

Such is the general character of these absences, faints, spells, etc., 
as they are popularly called ; varying, however, according to the cir- 
cumstances of the moment and the condition of the patient. They fre- 
quently exist for a long time without the patient paying much atten- 
tion to them. In a gentleman now under my charge they occurred 
several times in the course of the day when walking, riding on horse- 
back, sitting quietly in his library, engaged in conversation, or eating. 
The continuity of his acts was scarcely interrupted, and those about 
him never noticed that anything was wrong. 

In the case of a young lady they occur generally at the dinner- 
table. She drops her knife and fork, looks steadily to the front, ceases 
to eat, and in about two seconds resumes her occupation with a long- 
drawn inspiration. Those near her observe that her countenance be- 
comes very pale, and that she does not hear or see. 

Sometimes these attacks, slight as they are, are followed by pain in 
the head, vertigo, confusion of ideas, numbness, and other evidences of 
nervous derangement, which may last for several hours, and which be- 
come more pronounced as the epileptic condition becomes more con- 
firmed. 

2. Unconsciousness, loith Evident though Local Spasm. — In this 
variety the loss of consciousness is of longer duration than in the pre- 



EPILEPSY. 669 

ceding, and is attended with convulsions light in character, but yet ap- 
parent to those around. The eyes are fixed, as in the first variety, the 
mind becomes a blank, and there is a sensation of vertigo immediately 
before the loss of consciousness, and at the time of its restoration. 
The face usually becomes pale first and then red, or either of these con- 
ditions may occur without the other being observed. 

The spasms may be very slight. Sometimes there is momentary 
strabismus, at others retraction of the angles of the mouth on one or 
both sides, rotation of the head or a sudden drawing of it backward, or 
the tongue is thrust forward and the jaws close on it, inflicting slight 
injury. Again, the chair in which the patient may be sitting is pushed 
back with some force, and the body is bent forward, or the muscles of 
the neck may be affected, and the circulation thus interrupted in the 
veins of the neck, causing a dark hue of the complexion. 

Sometimes the spasms have an appearance of being volitional. A 
patient under my charge tugs violently at his hand ; another walks 
about the room, but without taking any determinate course ; a young 
lady leaves her chair and stands upon another one at some distance 
from her, and another talks all kinds of gibberish. My experience of 
such cases is in accordance with that of Reynolds, 1 to the effect that 
there is no recollection of these acts. These attacks are often preceded 
by prodromata of various kinds. The duration rarely exceeds a minute, 
and is generally much less. 

3. Unconsciousness, with General Tonic and Clonic Convulsions. 
— Prodromata may or may not be present. In any event the paroxysm 
occurs suddenly. The first circumstance may be a cry of a very peculiar 
character, somewhat resembling the bleating of a young lamb. The 
eyes become fixed, and the patient falls to the ground, usually with a 
bound, as if he is shot. The loss of consciousness occurs with the cry, 
or with the fixedness of the gaze. 

The muscles are now thrown into a state of tonic contraction ; the 
respiration is impeded, or altogether arrested ; the face, if at first pale, 
becomes dark ; the pupils are dilated, and sensibility is entirely abol- 
ished. 

Careful examination of a patient in this stage of the paroxysm re- 
veals some important features : the body is rigid, but is usually inclined 
more to one side than the other, in the position of a tetanic patient 
with pleurosthotonos ; the eyes are open, and are twisted to one side ; 
the face is likewise more retracted on one side than the other ; the 
sterno-cleido-mastoid muscles, and others of the neck, stand out like 
thick cords ; the carotids throb with force ; the veins of the head and 
neck are turgid with black blood, and the pulse is usually weak and 
fluttering. 

After this stage has lasted for a period varying from two or three 
1 "System of Medicine," vol. ii., p. 261, article " Epilepsy." 



670 CEREBROSPINAL DISEASES. 

seconds to half a minute, a great change ensues. The unconsciousness 
continues, but the general tonic spasm relaxes, and clonic convulsions 
take its place. These are general, but are ordinarily more strongly 
marked on one side of the body than on the other. The muscles of the 
face are alternately contracted and relaxed ; the tongue is 6ften thrust 
between the teeth, and, the jaws being closed upon it, it is terribly in- 
jured ; the upper and lower extremities are in a state of continued agi- 
tation, and the contents of the bladder, rectum, and vesiculae seminales, 
may be evacuated. 

The respiration is forced and irregular, froth issues from the mouth, 
and, if the tongue has been bitten, it is colored with blood. 

The muscles of the neck do not relax to any considerable extent ; 
consequently the veins remain distended, and the face continues to bo 
livid. The pupils oscillate, sometimes being dilated and then contract 
ed, or one may be contracted and the other dilated. The heart beats 
with great irregularity, both as to force and frequency. 

This stage may last from a few seconds to five minutes. Cases of 
longer duration are on record, but they are exceedingly rare. 

The third stage of the paroxysm is characterized by the gradual 
return of consciousness. The patient, though still somewhat convulsed, 
looks around him, and gives evidence of returning sensibility in other 
ways. The pupils cease their disorderly movements, and are contracted ; 
the respiration and pulse become more regular, and he may even attempt 
to speak. It often happens that little spots of extra vasated blood make 
their appearance under the skin of the forehead, eyelids, cheeks, and 
sometimes on the neck and breast. These disappear in a few days. 

The duration of this stage is from a few seconds to four or five 
minutes, and it is often so slightly marked as to escape observation. 

With the cessation of the convulsive movements the stage of stupor 
usually supervenes, though it may be entirely absent, especially in old 
cases of epilepsy. During this stage there are sometimes clonic spasms 
of no great degree of severity. It may last a few minutes or several 
hours. When the patient arouses from it, he generally has headache, 
and a feeling of lassitude and soreness of the muscles, from the violent 
contractions they have undergone. 

4. Irregular or Aborted Paroxysms, — In these it may happen that 
the loss of consciousness is not complete, or that the patient has con- 
vulsive movements partial in character and accompanied simply by ver- 
tigo, or he may have unconsciousness lasting for an hour or more, 
during which he performs automatic acts, of which he has no recollec- 
tion, but which are not accompanied by any movements that can prop- 
erly be called spasmodic. 

In his interesting lecture on " Apoplectiform Cerebral Congestion," 
Trousseau * cites a number of cases which were clearly instances of 
1 Op. cit. } Bazire's translation, pp. 19, etseq. 



EPILEPSY. 671 

irregular or abortive epileptic paroxysms. Among them is that of a 
magistrate whose sister was an inmate of a lunatic asylum. He was 
president of a provincial tribunal. One day he got up all of a sudden, 
muttered a few unintelligible words, and went to the deliberating-room. 
The usher followed him, and saw him make water in a corner. A few 
minutes afterward he returned to his seat, and again listened with in- 
telligence and attention to the pleadings momentarily interrupted. He 
had no recollection of the incredibly incongruous act he had committed. 
This gentleman belonged to a literary society, which held its meetings 
at the H6tel-de-Ville, of Paris. At one of these, during the discussion 
of an important historical point, he was seized with vertigo. He ran 
quickly down to the Place de H6tel-de-Ville, and walked about for a 
few minutes on the quays, avoiding with success both carriages and the 
passers-by. On recovering himself he perceived that he had come out 
without his great-coat and his hat. He therefore returned to the meet- 
ing, and resumed with a perfectly lucid mind the historical discussion in 
which he had already taken a very active part. He retained no recol- 
lection whatever of what had occurred between the beginning of the 
attack and the moment he recovered himself. 

Many cases similar to these might be cited from other authors. 
From a number which have happened in my own experience I adduce 
the following: 

J. H. consulted me for epilepsy in the summer of 1869. His ordi- 
nary attacks were of the fully-developed form; but upon two occasions 
they were different from any with which he had previously been af- 
fected. On one of these, while overlooking some workmen, he was 
observed to put his hand to his head, and then sudddenly to run toward 
a fence, which he speedily climbed. Jumping down into the back-yard 
of the adjoining house, he seized a stick of wood near by, and made a 
furious onslaught on the door and windows. While thus engaged he 
was seized by several men, and forcibly held, notwithstanding his strug- 
gles. While thus being restrained he recovered his consciousness, but 
had no recollection of any thing which had taken place after he had put 
his hand to his head, which action he said was due to severe pain with 
vertigo. The duration of the attack was not over three minutes. 

On the other occasion he was seized with pain and vertigo while 
engaged in paying a bill at a coal-yard. He rushed into the street, 
and began to turn rapidly round. He was seized and held till he re- 
covered his consciousness. This attack lasted about four minutes. 

Subsequently he had a similar paroxysm in my consulting-room. 
His face suddenly became very pale, his eyes were fixed, and his pupils 
oscillated. Suddenly he rose from the chair, grasped the mantel-piece 
for an instant, and then rushed violently around the room, throwing his 
arms about, and uttering a peculiar inarticulate cry. I made no at- 
tempt to restrain him, and in about two minutes he became calm. 



672 CEREBROSPINAL DISEASES. 

During the whole paroxysm his face was pale, and at its close the pu< 
pils were dilated. He had no recollection of any thing which had oc- 
curred after he rose from the chair, but was conscious then of vertigo. 

Another case is that of a girl brought to my clinic at the Bellevue 
Hospital Medical College during the summer of 1869. She had been 
severely injured in the skull by a fall against a mass of old iron. Ne- 
crosis subsequently ensued, and several large pieces of the external 
table were exfoliated. While before the class, she started to her feet, 
and walked several times around the closed area. She was unconscious, 
and to all appearance insensible. When the paroxysm was over she 
returned to her seat. The duration did not exceed a minute, and there 
was no excitement or delirium. 

Another patient, a partner in an extensive mercantile establish- 
ment, who was subject to attacks of both the grand, and petit mal, left 
his office at about eleven o'clock for the purpose of getting a signature 
to a paper of some kind from a gentleman whose place of business was 
a few minutes' walk distant. Not returning by three o'clock, inquiry 
was made, and it was ascertained that he had visited the office, obtained 
the signature, and had left in apparently good health before half -past 
eleven. Since then nothing had been heard of him. He did not make 
his appearance at his own office till nearly five o'clock. 

The last thing he recollected was passing St. Paul's Church at the 
corner of Broadway and Vesey Street, just as the congregation was 
coming out after morning service. It was subsequently ascertained 
that he had gone to Brooklyn after getting the signature he wanted, 
had visited a newspaper-office and purchased a paper ; had returned to 
New York, entered an omnibus at the Fulton Ferry, left it at the corner 
of Twenty-third Street and Fifth Avenue, entered the Fifth Avenue 
Hotel, and while there recovered his recollection. 

But none of these cases, nor any of which I have seen any report, 
are equal in interest to one which occurred in my practice during the 
autumn of 1875. The patient, who was engaged in active business as a 
manufacturer, left his office at about 9 a. m., saying he was going to a 
florist's to purchase some bulbs. He remained absent eight days. He 
was tracked all over the city, but the detectives and friends were always 
an hour or more behind him. It- was ascertained that he had been to 
theatres, to hotels, where he slept, to shops where he had made pur- 
chases, and that he had made a journey of a hundred miles from New 
York, and, losing his ticket and not being able to give a satisfactory 
account of himself, was put off of the train at a way-station. He had 
then returned to New York, passed the night at an hotel, and on the 
eighth day, at about ten o'clock, made his appearance at his office. He 
had no recollection of any one event which had taken place after leav- 
ing his place of business, eight days previously, till he awoke on the 
morning after his return to the city, and found himself in an hotel at 



EPILEPSY. 673 

which he was a stranger. It was ascertained beyond question that in 
all this time his actions had been entirely correct to all appearance, that 
his speech was coherent, and that he had acted entirely in all respects 
as any man in the full possession of his mental faculties would have 
acted. He had drunk nothing but a glass of ale, which he took with 
some oysters at a restaurant in Sixth Avenue. 

It could not be ascertained that this patient had ever had an epilep- 
tic paroxysm ; but he had a year previously been under my charge for 
cerebral symptoms, indicating the existence of chronic basilar menin- 
gitis, and only a week before his disappearance I had discharged him 
cured, after a month's treatment for severe pain in the head, dizziness, 
paralysis of the third nerve on the right side, and extreme insomnia. 
There were all the indications of specific cause, and I had treated him 
with large doses of the iodide of potassium, as on the former occasion. 

Most, if net all, of the cases of " double consciousness " that have 
been reported are doubtless epileptic in character. An interesting case 
of the kind has been related by M. Azam. 1 It is that of a young woman 
who, after having suffered from hysteria and convulsions, had two dis- 
tinct phases of existence, living, in fact, two separate and different lives, 
and exhibiting different likes and dislikes and mental characteristics. 

Another case was that of a sergeant, reported by Dr. Mesnet, 8 who, 
after receiving a severe wound of -the skull, had paroxysms charac- 
terized by total change in his mentality, and obliviousness of all acts 
performed in his normal state. During these periods he was con- 
scious, and acted in a logical and coherent manner. 

5. Unco7isciousness icith Hallucinations. — In this form of epilepsy, 
which I described in a paper read before the American Neurological As- 
sociation, June 18, 1880, 3 the characteristics are conscious hallucinations, 
followed by unconsciousness but unattended by muscular spasm. I have 
had the opportunity of seeing two cases (one since the reading of the 
paper) while the paroxysms were present, and in neither was there the 
least spasmodic action. I quote part of the description of one of the 
cases, that of a young woman on which the memoir in question is based : 

" I had the opportunity of witnessing seventeen paroxysms. Some- 
times they were preceded by a well-marked aura, and this was always 
a sensation apparently somewhere within the cranium, but not capable 
of being exactly localized or described. This was never felt until 
within the last two years. It lasted only a second or two, and was im- 
mediately followed by the ' vision.' 

1 " Amnesie periodique, ou dedoublement de la vie," Annates Medico-psychologiques, 
July, 1876. 

2 Union Medicate, July 21 and 23, 18*74. Translated in Ihe Chicago Journal for 
Nervous and Mental Disease, January, 1875. 

3 " On Thalamic Epilepsy," Archives of Scientific Medicine, August, 1880. Also, Neuro- 
logical Contributions, No. Ill , 1881. 

44 



674 CEREBRO-SPINAL DISEASES. 

" The first paroxysm of this series which I witnessed was ushered 
iu by the aura. She had hardly time to say, ' It's coming,' when the 
hallucination began. She described it as consisting of a large white 
bear in motion before her on the carpet. It seemed to be walking 
slowly to and fro, its head bent toward the floor as if scenting some- 
thing. I closely watched her, and could detect no spasm anywhere. 
She spoke clearly, without hesitation, and with entire distinctness. 
The pupils were normal. 

"I had taken out my watch to time the duration of the attack. 
Thirty -five seconds elapsed, and then her pupils suddenly dilated, her 
head fell forward, and her left hand, which was at this instant pointing 
in the direction of the visional bear, dropped to her side. I pinched 
the skin of her face, then of each hand, without eliciting any evidence 
of cutaneous sensibility. I took up a fold of skin on each forearm 
just above the wrist and stuck a cataract-needle, which was at hand, 
through it, with a like result. Her pulse — I had not felt it during the 
existence of the hallucination — was beating at the rate of about sixty 
a minute, and was full. Her face had not altered in color, nor was 
there any other change in it except such as was due to relaxation of 
the muscles — such as is present in sleep. The eyelids were closed, but 
not spasmodically. She remained in this state exactly twenty-eight 
seconds, breathing perhaps a little more slowly and deeply than before 
the accession of the paroxysm. Suddenly she raised her head, looked 
inquiringly around her for a moment, and then, as if becoming aware 
of a sensation, looked at both her arms where I had pricked them. A 
drop of blood was oozing from each puncture. She asked what it was, 
and then, without waiting for an answer, exclaimed, ' You have bled 
me ! ' She was then entirely herself, and talked coherently, and without 
the least excitement, about the hallucination. 

" While making memoranda of the phenomena I had observed, and 
while she was walking up and down the floor, she said that she was 
going to have another attack, as she felt the peculiar sensation again 
in her head. She had no sooner uttered the words than the vision 
came. ' It's a girl this time ! ' she exclaimed — ' a girl with long auburn 
hair, and a cap on her head ; she looks like a French nurse. I think I 
will sit down, for if I do not I shall fall as soon as I become insen- 
sible ; ' saying which, she quietly sat down in a large arm-chair. 

"I pinched the skin of her right hand. ' Oh ! ' she exclaimed, 'I 
feel that ; I am not insensible yet ; I see everything in the room as 
well as I do the girl who is not here. I can feel the least touch, and 
my hearing is as good as ever.' 

" I asked her what ' the girl ' was doing. ' Oh, nothing,' she replied ; 
' she is only standing there in front of the fireplace, looking at me.' 

" I told her to shut her eyes, and then to tell me if she still saw 
< the girl.' 



EPILEPSY. 675 

" * Yes,' she answered, * just as distinctly as I did when they were 
open.' 

"At forty-one seconds she became unconscious, and remained 
in this state for one minute and five seconds, awaking — I say awak- 
ing, for her appearance was like that of a person asleep — sudden- 
ly, and apparently in a normal condition of mental and physical 
health." 

Subsequently, from inattention to treatment on the part of the pa- 
tient, the paroxysms passed into others with strong muscular contrac- 
tions, and she exhibited indications of a tendency to the perpetration 
of acts of violence. 

In all, six cases of this interesting form of epilepsy have come 
under my observation ; and I have learned of others being recognized 
by several physicians of competent powers of observation. 

Relative to the mental disturbance which sometimes ensues upon epi- 
leptic paroxysms, Dr. Hughlings Jackson ' has recently given some inter- 
esting details relative to acts performed by epileptics during periods of 
unconsciousness. In his opinion such acts are automatic, not — to speak 
exactly — epileptic, but post-epileptic. " The condition after the parox- 
ysm is duplex : (1) there is loss or defect of consciousness, and there is 
(2) mental automatism. In other words, there is (1) loss of control, 
permitting (2) increased automatic action." The epileptic seizure may 
be so slight and transitory as to escape observation, but the slighter it 
is the more apt is the resulting automatism to be complex and elab- 
orate. 

Dr. Jackson gives a number of exceedingly interesting cases in illus- 
tration of his views, which in addition are enforced with much cogent 
reasoning. But, while in the main agreeing with him, I am scarcely 
prepared to deny that such unconscious attacks may not be substituted 
for the more fully-developed paroxysm instead of, as in his opinion, 
always following a seizure. 

Epileptic fits may take place at night during sleep, and the patient 
be unaware of their existence, unless he inflicts some injury on himself, 
such as biting his tongue, or is told of their occurrence by persons who 
may be in the same room with him. In two hundred and six of my 
cases the period of access is noted, and, of these, forty-seven were noc- 
turnal, and one hundred and fifty-nine diurnal. 

In the intervals between the paroxysms epileptics often exhibit cer- 
tain evidences of disordered mental, sensorial, and motor functions. 
Thus, as regards the first category, the memory may be impaired, and 
there may be diminished mental power. There are, however, many 
exceptions to this rule; and, even where there have been a great many 
attacks, the mind may preserve its normal degree of integrity. As 

1 " On Temporary Mental Disorders after Epileptic Paroxysms," " West Riding Lu- 
natic Asylum Medical Reports," vol. v., p. 105. 



676 CEREBROSPINAL DISEASES. 

Reynolds remarks, in regard to this point: " A patient may be epileptic 
and a lunatic; he may be epileptic and asthmatic, but there are some 
epileptics whose minds are as healthy as their lungs; and, so far as the 
natural history of epilepsy is concerned, it is a mistake to derive it from 
complicated cases." Still, in the majority of cases, it will be found that 
the mind sooner or later becomes involved, and it sometimes happens 
that a single attack causes marked intellectual deterioration. 

Derangements of sensibility are common from the beginning. 
Headache, a feeling of constriction around the forehead, and occasion- 
ally a pain at the back of the head, are noticed. Vertigo is also fre- 
quently present, as are also sensations of numbness in different parts of 
the body. The pupils are almost invariably dilated. 

The motor power of the patient is generally weakened without there 
being any decided paralysis. Twitchings of the muscles are not un- 
common, and there is often a general excitability of the reflex faculty 
of the spinal cord, by which jerkings of the limbs are produced by 
slight excitations. 

The circulation is generally sluggish, the extremities are cold, and 
the capillaries are turgid and inactive, so that, if the finger be pressed 
firmly upon the skin, a considerable period elapses before the white spot 
disappears by the refilling of the vessels. 

In examining with the ophthalmoscope the fundus of the eye in 
epileptics, we can often detect evidences either of cerebral congestion 
or of anaemia, and thus obtain valuable indications for treatment. For 
several years, in my lectures, I have constantly insisted on this point, 
and in my cliniques have exhibited several cases in which I had been 
guided to successful treatment by the ophthalmoscope. Drs. Kostle and 
Niemetshek, 1 of Prague, consider that the brain in epileptics is always 
anaemic, and that this condition is invariably found by ophthalmoscopic 
examination. According to these observers, the venous pulse is pro- 
duced when the eye is made anaemic, and they assert that the retina is 
anaemic, and that there is consequently venous pulsation in every case 
of epilepsy. That this opinion is erroneous, both as to the facts and 
inferences, I am very sure. Venous pulsation, so far from being indica- 
tive of anaemia, really shows the existence of the very opposite con- 
dition. My observations are, however, to the effect that venous pul- 
sation is present in many cases of epilepsy, and that it accompanies 
dilatation of the veins. 

There is no invariable rule relative to the occurrence of any par- 
ticular form of epilepsy in the same person. It thus often happens 
that all the varieties of paroxysm mentioned, except the irregular or 
aborted form, which is more rare, are met with in one individual. The 
more severe forms may occur at longer intervals, and the milder forms 

1 Prager Vierteljahrschri/t, H. 106, 107, 1870, and Quarterly Journal of Psychological 
Medicine, January^ 1871, p. 128. 



EPILEPSY. 677 

more frequently. As regards frequency, there are great variations. 
Some patients go a year or more without attacks, while others have 
several every day. It generally happens that the intervals become 
progressively shorter. As a rule, attacks of the milder forms are more 
frequent than the fully-developed paroxysm, and attacks of the latter 
are milder, as they are more frequent. 

Mania is sometimes a consequence of epilepsy. It comes on after 
the attack, and is rarely of more than a few minutes' duration. Those 
cases in which it precedes the paroxysm, and lasts several hours or 
dajs, are cases of mania conjoined with epilepsy — a combination which, 
as every insane asylum shows, is not uncommon. The mania of epi- 
lepsy is usually of a very exalted character, and during its existence 
the subject may commit homicide or other crimes. 

The mental state of epilepsy has been well studied by Falret, 1 and 
a very interesting case has been recently reported by Dr. Thorne, 2 in a 
paper entitled M Masked Epilepsy." In this instance the patient often 
returned to his home without being able to give any account of what 
he had been doing or where he had been. During these attacks he was 
frequently the subject of that form of mental derangement called klep- 
tomania. Generally they ensued on paroxysms either of the grand or 
petit ?nal, but sometimes they were substituted for the regular seiz- 
ures. He had no recollection of what occurred during the attacks. 
Sometimes he was furiously excited in them, and would endeavor to 
injure himself and others in his blind rage. 

Relative to the diagnosis of the remarkable paroxysms, the main 
feature of which is unconsciousness, or rather non-recollection of 
consciousness, in which the individual acts apparently automatically, 
great difficulties exist. Probably nothing short of a full history of the 
case, from infancy up, will suffice for the recognition of the real nature 
of the phenomena. There appears to be an idea in the minds of some 
physicians, that every outrageous criminal act is the result of epilepsy, 
and so wide-spread is this notion, that now the first plea of the murderer 
is, that he " knew nothing about it ; " and the fact that an individual 
who has perpetrated a murderous outrage is the subject from time to 
time of epileptic seizures, is regarded as sufficient to absolve him from 
all responsibility for his actions. The fact of a discolored spot on his 
pillow, or of an infantile convulsion, is seized upon as a valid reason 
for acquittal, or even for setting aside a verdict found after a full and 
fair trial. In the first place, it must be understood that an undoubted 
epileptic is just as capable of murdering for revenge or gain as is a 
healthy person, and that he is just as accountable, and should accord- 
ingly suffer the full penalty of the law for his conduct. At the same 

1 " De l'etat mental des epileptiques," Archives generales de mSdeci7ie ) Decembre, I860, 
et Avril et Octobre, 1861. 

2 "St. Bartholomew's Hospital Reports," 1870. 



678 CEREBROSPINAL DISEASES. 

time, it is not to be questioned that acts of violence may be perpetrated 
during seizures which are either epileptic or the direct consequence of 
an epileptic paroxysm. It is only by the most thorough and careful 
inquiry into all the motives for and circumstances attending upon the 
act, as well as all the antecedents of the individual, that a proper 
discrimination can be made. Each case must be determined for itself ; 
there are no rules applicable invariably to all. 

The medico-legal relations of epilepsy do not, however, come with- 
in the scope of the present treatise. 

Paralysis may follow epilepsy, but, unless the case is complicated 
with some organic disease of the brain or spinal cord, the loss of 
power is temporary. 

Causes. — Among the predisposing causes of epilepsy, hereditary 
tendency stands first. Reynolds 1 states that, in about one-third of the 
cases under his observation, hereditary taint existed. He does not, by 
this statement, however, mean to assert that epilepsy existed in one- 
third of the parents, but that some disease of the nervous system, 
more or less closely allied to epilepsy, was present in either the parents, 
the grandparents, the aunts, uncles, brothers, or sisters. Only twelve 
per cent, of his cases gave a distinct history of epilepsy in either 
branch of their families. 

Herpin, 2 of sixty-eight cases, found that ten were descended from 
epileptic ancestors. 

Delasiauve, 3 of three hundred cases, found decided evidence of 
hereditary tendency in thirty-three. In one hundred and sixty-seven 
there were no data, and in one hundred and twenty hereditary taint 
was denied. Of the thirty-three cases, five were descended from epi- 
leptic ancestors. 

Sieveking 4 found that hereditary influence was present in 11.1 per 
cent, of his cases. 

In my own experience I have notes in regard to this point in three 
hundred and ninety-six cases. Of these, sixty-four had epileptic fa- 
thers, mothers, grandparents, uncles, aunts, brothers, or sisters, and 
forty-eight had relatives insane, hysterical, cataleptic, affected with 
severe neuralgia, or of remarkably irritable nervous systems. 

Sex does not appear to exercise any appreciable influence as a pre- 
disposing cause. Of five hundred and seventy-two cases noted by my- 
self, two hundred and ninety-eight were in males and two hundred and 
seventy-four in females. Other authors have, however, had directly 
opposite experience. 

Age has a very decided influence. Reynolds gives the following 
table of one hundred and seventy-two cases collected by himself : 

1 Op. tit, p. 253. 

8 " Du pronostic et du traitement curatif de Tepilepsie," Paris, 1852, p. 325. 

3 Op. cit, p. 189. * « On Epilepsy," etc., London, 1858, p. 14. 



EPILEPSY. 



679 



Age at Commencement. 



Under 10 years 

Between 10 and 20 years 
Between 20 and 44 years 
Over 45 years 

Total 



Males. I Females. TotaL 
I 



10 

66 

25 

1 



102 



9 
40 
20 

1 



19 

106 
45 



172 



My own cases were as follows : 



Age at Commencement. 


Males. 


Females. 


Total. 


Under 10 years 


31 
178 

72 
17 


29 

151 

71 

23 


60 


Between 10 and 20 years , 


329 


Between 20 and 45 years 


143 


Over 45 years 


40 






Total 


298 


274 


572 



It is thus seen that the period of life between ten and twenty years 
is that at which epilepsy is most apt to occur. The experience of oth- 
ers is to the same effect. The influence of temperament has been 
thought important by some writers. But, aside from the different 
opinions entertained relative to the characteristics of the temperaments, 
it is by no means established that, even when strictly defined, tempera- 
ment exercises any effect as a predisposing cause. I have no accurate 
records on this point, though so far as my memory serves me I have 
observed no marked predominance of epileptics with any temperament. 

The exciting causes may very properly be classified as psychical, 
eccentric, general organic changes, and physical influences. Relative 
to the influences of these causes, Reynolds gives the following table : 

Nature of Cause. Eo. of Cases. 

I. Psychical — such as fright, grief, worry, overwork 29 

II. Eccentric irritation — dentition, indigestion, venereal excesses, dys- 
entery, etc 16 

ILL General organic changes — fatigue, pregnancy, miscarriages, rheu- 
matic fever, scarlet fever, diphtheria, pneumonia 9 

IV. Physical influences — blows on head, falls, insolation, cuts 9 

In my own cases no exciting cause could be assigned in one hun- 
dred and seventy-seven. The remaining three hundred and ninety-five 
cases were, according to the evidence received, caused as follows : 

Fright 35 

Anxiety 17 

Grief 30 

Over mental exertion 48 

Dentition 21 

Indigestion 83 

Carried forward 184 



680 CEREBROSPINAL DISEASES. 

Brought forward 184 

Venereal and sexual excesses 60 

Menstrual derangement 56 

Blows on the head 24 

Peripheral wounds and injuries 4 

Falls 13 

Sunstroke. 17 

Scarlet fever 3 

Measles 3 

Diphtheria 9 

Pregnancy 3 

Syphilis 13 

Malaria 6 



Diagnosis. — The diagnosis of epilepsy presents no difficulties to the 
careful observer. It may, however, be confounded with several condi- 
tions, the principal of which are cerebral congestion, cerebral haemor- 
rhage, hysteria, the convulsions of infancy and of Bright's disease, 
poisoning by opium and alcohol, syncope, and with the convulsions of 
epileptiform character which occur in the course of certain organic dis- 
eases of the brain. 

The diagnosis from cerebral congestion and cerebral haemorrhage 
has already been given in the chapters treating of those affections. In 
hysteria, the convulsions, which are sometimes epileptiform in charac- 
ter, are preceded or accompanied by other evidences of the hysterical 
state. Consciousness is rarely entirely lost, the tongue is not bitten, 
and there is no subsequent stage of stupor. 

The convulsions of infancy not epileptic are not repeated but from 
a readily-ascertained exciting cause, such as dentition, indigestion, falls, 
etc. So far as the paroxysm is concerned, I know of no specific points 
of difference; but it must be recollected that the paroxysm is not the 
only feature of epilepsy, and that it is the only feature of infantile con- 
vulsions. These latter may pass into epilepsy ; but, if they do not, I 
have never been able to find a single case in my experience r n which 
epilepsy ensuing in adult life has been preceded by the ordinary infan- 
tile convulsions. In Bright's disease, though the convulsions may be 
epileptiform in character, coma is the principal feature, and the history 
of the case will further serve to render the diagnosis exact. The same 
remarks are applicable to poisoning by opium and alcohol. 

From syncope epilepsy is distinguished by the facts that the loss of 
consciousness is sudden and complete, that the pulse is not feeble, and 
that recovery is rapid. These remarks apply to the milder attacks with- 
out convulsions. From the more severe forms of the paroxysm the dis- 
tinction is too obvious to require amplification. 

In organic diseases of the brain, such as tumors, softening, sclerosis, 
etc., the accompanying symptoms, pain, paralysis, tremor, imbecility, 



EPILEPSY. 681 

difficulties of speech, and derangements of the special senses, will serve 
to distinguish them from epilepsy. 

Epilepsy is often assumed by designing persons for purposes of 
fraud. In such cases the pretender usually overacts his part ; his 
sensibility is not abolished, as may readily be ascertained by putting 
the end of the finger on the conjunctiva, and the size of the pupils is 
not altered. 

Prognosis. — The prognosis depends to a great extent on the dura- 
tion of the disease. Recent cases can often be cured, but those which 
have lasted for several years are rarely brought to a favorable termina- 
tion. Among the other unfavorable elements are the existence of 
hereditary influence, the beginning of the disease late in life, the pres- 
ence of material mental weakness, and the existence of long intervals 
between the attacks. 

As regards the probability of the supervention of any form of in- 
tellectual derangement or debility, the most important ascertained 
point is that the mild paroxysms unattended by convulsions are more 
productive of mental decay than the severe form of seizure. The oc- 
currence of the first attack late in life is likewise a predisponent to 
dementia. 

I have never, in my own experience, known death to take place dur- 
ing a paroxysm of true epilepsy ; such cases, however, do occur. Usu- 
ally, some intercurrent affection carries the patient off, though even 
with this liability life is sometimes astonishingly prolonged. I am 
acquainted with the case of a lady who is now sixty-five years of age, 
and who, since her tenth year, has averaged six paroxysms daily, all of 
the severest character. Her mind is almost entirely gone, but physi- 
cally her health is excellent, and to all appearance she may live twenty 
years longer. 

I am not aware of any exact observations tending to show the rela- 
tive danger to life of attacks of the milder and severer forms ; though 
it is reasonable to suppose that, so far as regards the occurrence of 
death during the paroxysm, the convulsive form is more fatal. 

forbid Anatomy. — In post-mortem examinations of persons dying 
epileptic, abnormal conditions are found in every part of the brain and 
spinal cord. Some of these lesions are undoubtedly secondary, others 
unessential, while those which may be considered primary vary in their 
seat and character. In a great many cases, perhaps the majority, no 
lesions are discoverable. 

No one has been more thorough in the search for the essential cause 
of epilepsy than Schroeder van der Kolk ; * though his observations can 
scarcely be regarded as yielding conclusive results, they serve to show, 

1 " On the Minute Structure and Functions of the Medulla Oblongata, and on the Proxi- 
mate Causes and Rational Treatment of Epilepsy," " Nev Sydenham Society Transit 
tions," London, 1859. 



682 CEREBRO-SPINAL DISEASES. 

when taken in connection with the pathology of the disease in ques- 
tion, that its seat is mainly in the medulla oblongata, with second- 
ary implication of other parts of the cerebro-spinal nervous system. 
Oftentimes, in accordance with other pathologists, he found, noth- 
ing to account for the affection, but at others he found hardening 
and contraction of the medulla oblongata, and again degeneration 
of the brain either as a consequence or cause of the disease. Mi- 
croscopical examination sometimes showed him the medulla indu- 
rated, sometimes softened, and, as a constant phenomenon, "whether 
the patient died in or out of the fit, great redness and vascular ten- 
sion in the fourth ventricle, penetrating into the medulla oblongata 
sometimes to a considerable depth." These appearances were due 
to enlargement of the blood-vessels, as was shown by microscopical 
measurements. It is probable, however, as Schroeder van der Kolk 
asserts, that the lesions in question are the results, and not the causes, 
of the paroxysms. 

Other observers have not so uniformly found this enlargement of 
the blood-vessels of the medulla. In three cases of death occurring in 
epileptics, in which I have had the opportunity of making post-mortem 
examinations, they certainly did not exist, nor was there any other le- 
sion detected by the most careful microscopical exploration. In one 
other case the vessels of the medulla oblongata were enlarged, and there 
was amyloid degeneration of the pituitary body. 

•Fox 1 gives the following list of the post-mortem appearances : 
Foreign bodies developed on the meninges, in the ventricles, in the 
cortical substance ; increase of subarachnoid fluid or distention of the 
ventricles by serum, induration, softening, and general swelling of the 
cerebral mass ; general or partial hyperemia, cysts, tubercles, cancers, 
exostoses, periosteal growths, thickening, or some change of the arach- 
noid or the pia mater ; abnormal thickness or abnormal thinness of the 
cranial bones ; excessive size of head, increase of the volume of the 
cranial cavity, deformities or abnormality in the conformation of this 
cavity ; caries of the cranial bones ; pus between the bone and the dura 
mater ; acute or chronic hydrocephalus, hydatids, ossification of the 
dura mater, tubercle of the dura mater or pachymeningitis, abscess in 
the cerebral tissue, spots or regions of haemorrhage ; various traumatic 
lesions ; alterations of the pineal gland ; inequality of weight and size 
of the cerebral hemisphere ; various lesions connected with blood-ves- 
sels — aneurism, embolism, atheroma, increase in size of the capillaries 
in the medulla oblongata, fatty degeneration of some portion of the 
medulla oblongata ; capillary dilatation in the pons and cerebellum ; 
haemorrhage of pons; anaemia of brain, either from disease of vessels or 
dependent upon general anaemia, etc., etc. 

1 " The Pathological Anatomy of the Nervous Centres." London, 1874, p. 805. 



EPILEPSY. 683 

Indeed, no point is more thoroughly established than that epilepsy 
results from very different morbid conditions, and that they are simply 
the starting-points in the majority of cases. The true lesion has not 
yet been detected, and in fact, as we shall presently see when discuss- 
ing the pathology of the disease, there may be no necessary anatomical 
lesion whatever. 

Pathology. — The points which may be considered as to some extent 
established relative to the pathology of epilepsy are briefly summarized 
as follows by Reynolds : x 

" 1. That the seat of primary derangement is the medulla oblongata 
and upper portion of the spinal cord. 

" 2. That the derangement consists in an increased and perverted 
readiness of action in these organs, the result of such action being the 
induction of spasm in the contractile fibres of the vessels supplying the 
brain, and in those of the muscles of the face, pharynx, larynx, respira- 
tory apparatus, and limbs generally. 

" By contraction of the vessels the brain is deprived of blood, and 
consciousness is arrested; the face is or may be deprived of blood, and 
there is pallor ; by contraction of the vessels which have been men- 
tioned, there is arrest of respiration, the chest-walls are fixed, and the 
other phenomena of the first stage of the attack are brought about. 

" 3. That the arrest of breathing leads to the special convulsions of 
asphyxia, and that the amount of these is in direct proportion to the 
perfection and continuance of the asphyxia. 

" 4. That the subsequent phenomena are those of poisoned blood, 
i. e., of blood poisoned by the retention of carbonic acid, and altered 
by the absence of a due amount of oxygen. 

" 5. That the primary nutrition-change, which is the starting-point 
of epilepsy, may exist alone, and epilepsy be an idiopathic disease, i. e., 
a morbus per se. 

" 6. That this change may be transmitted hereditarily. 

" 7. That it may be induced by conditions acting upon the nervous 
centres directly, such as mechanical injuries, overwork, insolation, emo- 
tional disturbances, excessive venery, etc. 

"8. That the nutrition-changes of epilepsy may be a part of some 
general metamorphosis, such as that present in the several cachexia? — 
rheumatism, gout, syphilis, scrofula, and the like. 

" 9. That it may be induced by some unknown circumstances deter- 
mining a relative excess of change in the medulla during the general 
excess and perversion of organic change occurring at the periods of 
puberty, of pregnancy, and of dentition. 

1 Op. cit., p. 275, and more fully stated in his " Treatise on Epilepsy, its Symptoms, 
Treatment, and Relations to other Chronic Convulsive Diseases," London, 1861, chapter 
v., p. 238. 



* 



684 CEREBRO-SPINAL DISEASES. 

" 10. That it may be due to diseased action, extending from con- 
tiguous portions of the nervous centres or their appendages. 

" 11. That the so-called epileptic aura is a condition of sensation or 
of motion, dependent upon some change in the central nervous system, 
and is, like the paroxysm, a peripheral expression of the disease, and 
not its cause." 

While admitting the correctness of these conclusions, they do not, in 
my opinion, tell the whole story of the theory of epilepsy. In very 
many memoirs Dr. Brown-Sequard has pointed out the dependence of 
the affection upon injuries of the upper part of the spinal cord, and 
upon irritations existing in various parts of the body. His researches, 
and facts observed every day by physicians who see many cases of epi- 
lepsy, show very conclusively that the starting-point is often in the 
sympathetic nerve — the nerve by which the calibre of the blood-vessels 
is regulated. 

Neither can I accept the view that the first intra-cranial condition 
producing a paroxysm is in all cases spasm of the blood-vessels and the 
consequent deprivation of the blood-supply to the brain. On the con- 
trary, I am very sure that the primary state is often paralysis of the 
cerebral blood-vessels and resulting hyperaemia. By this condition the 
medulla oblongata is thrown into a state of over-excitation, giving rise 
to convulsions, and consciousness is lost from the fact that the hemi- 
spheres participate. That convulsions, epileptiform in character, may be 
produced both by cerebral anaemia and cerebral hyperaemia, when either 
condition involves the medulla oblongata, is a fact which experiment 
has abundantly established, and that loss of consciousness follows either 
condition involving the hemispheres is equally certain. We have, con- 
sequently, two kinds of epilepsy — the one due to anaemia, the other to 
congestion — and it is to this fact that is due the circumstance that 
sometimes the paroxysms are prevented by measures which tend to in- 
crease the amount of blood in the brain, and at others by remedies 
which exercise a contrary influence. The existence of the two species 
of epilepsy is likewise shown by ophthalmoscopic examination — a point 
upon which I have already insisted. 

During natural sleep the amount of blood is, as I have elsewhere 
shown, decreased from the quantity which circulates in the cerebral 
blood-vessels during wakefulness. Epilepsy occurring during sleep is 
therefore of the anaemic variety. But it often happens that sleep 
passes gradually into stupor, from the fact that causes tending to in- 
crease the flow of blood to the brain, or to arrest its passage from this 
organ, are in operation. In such cases epilepsy of the congestive va- 
riety may be induced. 

In those cases in which the tongue is bitten, the medulla oblongata 
is probably always in a condition of hyperaemia ; and this state, as 
Schroeder van der Kolk has very conclusively shown, is mainly in the 



EPILEPSY. 685 

course of the roots of the hypoglossal nerve. The intermissions 
between the attacks are ingeniously explained by the same able 
observer, by likening the cells of the medulla oblongata to Leyden 
jars charged with electricity, or to the electrical organs of the conger- 
eel and torpedo. After being discharged, time is necessary for the 
reaccumulation of sufficient electricity to discharge them again ; and, 
when the cells of the medulla have once discharged themselves in 
an epileptic convulsion, a period must elapse before another access 
can take place. 

Nothnagel 1 believes that the pons Varolii and the medulla ob- 
longata are the seat of epilepsy, and that it is in these centres that 
we are to look for the anatomical changes. Although, as his own 
experiments as well as those of Hitzig show that epilepsy may be 
produced by irritation of the cortical substance of the brain, the fact 
only proves that such irritation is an exciting cause, and is no more 
to be regarded as indicating the cortex as the seat of the disease 
than the fact that irritation of the sciatic nerve, followed by epi- 
lepsy, indicates that part of the nervous system as containing the 
essential lesion. 

Operations for the removal of cortical tumors for the cure of epi- 
lepsy, and excision of portions of the cortex in which the motor cen- 
tres have been located, have rarely been followed by anything more 
than temporary relief. 

The foregoing remarks apply in the main to that form of epileptic 
seizure characterized by convulsion. In the imperfectly-developed at- 
tacks the implication of the medulla oblongata must be very slight, the 
hemispheres being the organs mainly affected, and the condition being 
sometimes anaemic, at others hyperemia 

It must not be supposed, from what has been said, that simple cere- 
bral anaemia and simple cerebral congestion, attended with epileptiform 
convulsions, are identical with the anaemia and congestion of epilepsy. 
This disease is cerebral anaemia or congestion with another element, 
the exact nature of which we do not understand, but which is certainly 
of such a character as to constitute the main differential point between 
epilepsy and any other affection. 

A chapter on epilepsy would be manifestly incomplete without a 
statement of the views held by Dr. Hughlings Jackson 2 relative to its 
pathology and natural history. According to this eminent authority 
those parts of the body suffer first and most, from convulsions or other 
manifestations of the disease, which are most frequently brought into 
volitional action, and those parts least which are most automatic in 

1 " Epilepsie," in Ziemssen's " Handbuch der speciellen Pathologie und Therapie," 
zwolfter Band, " Krankheiten des Nervensystems," ii., zweiter Halfte, pp. 250, el seq. 

8 " On the Anatomical, Physiological and Pathological Investigation of Epilept'Cb," 
"West Riding Lunatic Asylum Medical Reports," vol. hi., 1873, p. 315. 



C86 CEREBRO-SPINAL DISEASES. 

their operation. Thus he says, in a paper published in the Lancet, 
February 1, 1873 : 

" There are three parts where fits of this group mostly begin : 
(1) in the hand ; (2) in the face, or tongue, or both ; (3) in the foot. 
In other words, they usually begin in those parts of one side of the body 
which have the most voluntary use. The order of frequency in which 
parts suffer illustrates the same law. I mean that fits beginning in the 
hand are commonest ; next in frequency are those which begin in the 
face or tongue, and rarest are those which begin in the foot. The law 
is seen in details. When the fit begins in the hand, the index-finger 
and thumb are usually the digits first seized ; when in the face, the 
side of the cheek is first in spasm ; when in the foot, almost invariably 
the great-toe." 

As Dr. Jackson says, the spasm " prefers," so to speak, to begin in 
those parts which have the most voluntary uses ; in other words, in 
those parts which have the more leading, independent, separate and 
varied movements ; in other words still, in those parts the movements 
of which are last acquired — " educated." Physiologically, a voluntary 
part, the hand, for instance, is one which has the greater number of 
different movements at the greater number of different intervals ; that 
is, the more " varied " uses. An automatic part, the chest, for exam- 
ple, is one which has the greater number of similar movements at the 
greater number of equal intervals ; shortly, the more " similar " uses. 
Hence, convulsions which begin in the hand usually begin in the thumb 
and index-finger — in the most voluntary parts of the body. 

An epileptic paroxysm is a sudden, excessive, and rapid discharge 
of gray matter of some part of the brain. Instead of working off its 
force gradually and regularly, it explodes it, as it were. The gray mat- 
ter which is the seat of a" discharging lesion " is in a permanently ab- 
normal state of nutrition, and hence is permanently abnormal in func- 
tion. Thus a first fit is a discharge of a part which has for some time 
before been in a state of mal-nutrition. And a still further inference is 
that such " causes " of epilepsy as fright are only determining causes 
of the first explosion. 

In regard to this latter point, I am entirely in accord with Dr. Jack- 
son, We frequently see cases of epifepsy which, we are told, were ori- 
ginally caused by a mental shock of some kind. But if the shock were 
in reality the primary cause there should be no subsequent epileptic 
seizures. With the cessation of the cause the effect should cease. On 
the contrary, 'we find that after some time, generally quite long, w T hich 
of itself is sufficient to show that the continuance is not due to 
the initial convulsion, a second occurs, and then, after a shorter in- 
terval, a third, and so on. It is very evident that if the fright were 
the cause the fits would be more frequent at first, and less so subse- 
quently. 



EPILEPSY. 687 

But to return to Dr. Jackson's views : 

" Epilepsy is not a particular grouping of symptoms occurring 
occasionally ; it is a name for any sort of nervous symptom or group 
of symptoms occurring occasionally from local discharge, whether 
the discharge puts muscles in movement or not — that is, whether 
there be a convulsion or not matters nothing for the definition. A 
paroxysm of subjective sensation of smell is an epilepsy as much as is 
a paroxysm of convulsion ; each is the result of sudden local dis- 
charge of gray matter. 

" It does not matter for the definition whether there be loss of con- 
sciousness or not ; loss of consciousness is a fundamental thing in most 
of the accepted definitions. If there be no loss of consciousness there 
is, according to most physicians, not epilepsy, and the term ' epilepti- 
form ' is used. But, even when using the term epilepsy in the ordinary 
sense of the word, the separation into cases where there is, and where 
there is not loss of consciousness, has no physiological warrant. It is 
an arbitrary distinction of psychological parentage. Loss of conscious- 
ness is not an utterly different thing from other symptoms. It is not 
to be spoken of as an epiphenomenon or as a complication. Conscious- 
ness has of course anatomical substrata as much as speaking has. The 
sensori-motor processes concerned in consciousness are only in degree 
different from others. They are the most special of all special nervous 
processes, the series evolved out of all other (lower) series. 

" To lose consciousness is to lose the use of the most special of all 
nervous processes whatsoever. If those parts of the brain be first af- 
fected by strong discharge where the most special of all nervous pro- 
cesses lie, there will be loss of consciousness at the outset. If processes 
of subordinate series be discharged, loss of consciousness, of course, 
occurs later. For example, in cases of convulsions beginning in the 
hand, consciousness is in most cases lost as soon as or just before the 
leg is reached by the spasm. In these cases the internal process will 
be that consciousness is lost as soon as the most special of all processes 
are reached by the internal discharge (or since the sensori-motor pro- 
cesses underlying consciousness are evolved out of lower series), when 
as large a quantity of a subordinate yet important series is put hors de 
combat. But, of course, one does not locate consciousness so geograph- 
ically as the mere words we must use seem to imply. If a patient sud- 
denly loses, by any process, the use of any large part of either of the 
two highest divisions of the nervous system, he will lose consciousness. 

" The following are epilepsies : 

" (1) A sudden and temporary stench in the nose, with transient 
unconsciousness ; (2) a sudden and temporary development of blr.e 
vision ; (3) spasm of the right side of the face with stoppage of 
speech ; (4) tingling of the index-finger and thumb, followed by 
spasm of the hand and forearm ; (5) a convulsion almost immediately 



688 CEREBRO-SPINAL DISEASES. 

universal, with immediate loss of consciousness ; (6) certain vertigi- 
nous attacks. 

"All these six seizures are alike, in that each results from an 
occasional and excessive discharge of unstable gray matter. This is 
the one functional alteration of nerve-tissue underlying the different 
phenomena." 

Dr. Jackson then goes on to state that though these six kinds of 
seizures are alike physiologically, they are very unlike anatomically. 
That is, that the seat of the discharging lesion is different for each, 
and he urges that the efforts of physicians should be directed to the 
discovery of this seat from a consideration of the character and locali- 
zation of the manifestation. In a " destroying lesion," such, for in- 
stance, as is produced by cerebral haemorrhage, the scientific physician 
endeavors, by a careful study of the phenomena, to determine the situa- 
tion of the injury, but in cases of spasm the inquiries rarely relate to 
anything more than an attempt to ascertain the character of the con- 
vulsion. That this is true is not to be doubted. 

Further, Dr. Jackson asserts that by comparing the phenomena 
produced by a " destroying lesion " with those which result from a 
" discharging lesion " we may obtain very important data for further 
comparison. 

The experiments of Ferrier, Hitzig and Fritsche, and others, have 
proved conclusively that destruction of certain cortical areas is invari- 
ably followed by paralysis of certain muscles. Irritation of the same 
cortical areas, on the other hand, just as invariably produces spas- 
modic movements in the same muscles which were previously paralyzed 
by a destructive lesion. It is thus definitely proved that certain mus- 
cles, or groups of muscles, are in intimate relation with certain groups 
of cortical cells. The precise situation of these various groups of cells, 
or " centres," as they are termed, has been definitely located (see p. 
337). Thus we are enabled, in cases of epilepsy in which the spasms 
are unilateral, or confined to one limb, or to a part of one limb, to 
locate with precision that part of the cerebral motor cortex which is 
the seat of irritation, and which gives rise to the " discharges of motor 
force." Perhaps it would be too much to say that Dr. Jackson's views 
should be adopted in their entirety, but that they are in great part cor- 
rect every physician who has seen much of the very important disease 
to which they relate w T ill readily admit. The point in regard to which 
I should be most disposed to differ with him is that in which he too 
sweepingly, in 'my opinion, classes all " occasional, sudden, excessive, 
rapid and local, sensorial or motor phenomena " as epileptic. Thus, I 
am quite sure I have repeatedly witnessed " tingling of the index-fin- 
ger and thumb, followed by spasm of the hand and forearm," result 
from injury of the eccentric nervous system, from pressure on, or other 
injury of, the brachial plexus, for instance. Now, although such lesion 



EPILEPSY. 689 

may, under certain circumstances, produce such intra-cranial disorder 
as eventually to cause epilepsy, knowing what we do of the functions 
of the nerves and the effects of injuries to their trunks, we need not 
go so far as the gray matter for an explanation of the phenomena. Ex- 
periments on animals — and indeed as I have repeatedly witnessed in the 
human subject — show us that, even when a nerve-trunk is divided, irri- 
tation of its peripheral extremity will give rise to just such phenomena 
as Dr. Jackson calls epileptic, except in the one point — not an essential 
one — of " tingling." In a patient whom I saw in the Presbyterian 
Hospital a year or so ago, in the service of Dr. Post, the median nerve 
was exposed for the space of over two inches, and when it was touched 
with a probe or the finger, tingling in the skin below and spasm of the 
muscles of the forearm were at once produced. 

In the present state of our knowledge it appears to me better to 
regard no spasm as epileptic, which is not accompanied with loss, or at 
least disturbance of consciousness. The experiments of Hitzig, Fer- 
rier, and others, certainly throw a great deal of light on the nature of 
the epileptic phenomena, and give great support to many of Dr. Jack- 
son's arguments ; but they also show us that irritation of the gray 
matter of the brain will cause spasms, which, though partaking to a 
superficial examination of the character of epilepsy, are clearly not this 
disease, even as Dr. Jackson regards it. It is true that such irritation 
repeatedly made will in time so alter the properties of the gray matter 
as to lead to the production of spontaneous spasms, which may be epi- 
leptic, but that is quite a different thing. 

The experiments made by Dr. Roberts Bartholow ' on a patient 
under his charge, in the Good Samaritan Hospital in Cincinnati, show 
that both disorders of sensibility and spasm are produced in the human 
subject by irritation of the gray matter of the cerebral convolutions ; 
but in this case the phenomena disappeared as soon as the irritation 
ceased. Such transient results, clearly and distinctly due to an irrita- 
tion of the gray matter, may be epileptiform, but to my mind they are 
not epileptic. 

But quite recently Hitzig 2 has succeeded in producing true epilepsy 
in animals by irritating the cortical centres ; after a shorter or longer 
period — a day to five or six weeks — spontaneous, well-characterized 
epileptic convulsions ensued. The importance of such observations as 
those of Bartholow and Hitzig can scarcely be over-estimated. 

Brown-Sequard has shown that epilepsy may be caused by irritation 
of the peripheral nervous system, and it is quite certain that the tin- 
gling and spasm of the hand, which are at first perhaps only due to ec- 
centric lesions or derangements, may result in epilepsy. 

A case is now under my charge— a young gentleman from North 

1 American Journal of the Medical Sciences, April, 1874. 
8 " Untersuchungen ueber das Gehirn," Berlin, 1874, p. 271. 
45 



690 CEREBROSPINAL DISEASES. 

Carolina, whom I saw first over two years since. At that time it was 
only necessary to touch the left side of his neck, over the middle third 
of the sterno-mastoid muscle, to induce spasm of the muscles of the 
neck, shoulder, and face, on the same side, unaccompanied by loss of 
consciousness. This condition had apparently been induced in the first 
instance by his wearing a high shirt-collar, and in the beginning con- 
sisted of nothing more than a slight twitching of the muscles at the 
left angle of the mouth. Probably, if he had then ceased wearing that 
kind of collar, the excessive hyperesthesia of the eccentric nerves 
would have spontaneously ceased. As it was, an increase of all the 
phenomena took place; and finally, the least touch, even that of a 
camel's-hair pencil or a current of air, was sufficient to induce a spasm. 
Blistering, cauterization, and all kinds of local anaesthetics, were tried 
in vain, but eventually they ceased under the use of large doses of the 
bromide of sodium. But during all this time, unless an irritation of 
some kind — the lighter the more powerful, for strong pressure was not 
an efficient agent — there were no spasms. That such a condition was 
evidence of a strong epileptoid tendency I did not doubt, and nry fore- 
bodings of the ultimate result were fulfilled, for after the lapse of about 
two years he returned to me with no hypersesthsia of the skin of his 
neck, but with occasional fully-developed epileptic paroxysms, for which 
he is now under treatment. Inquiry, however, showed that they were 
the result of late hours and indiscretions in diet, and that apparently 
they had no connection with the former series of attacks. 

Relative to this subject of convulsion without loss of consciousness 
but appearing paroxysmally, I shall have some remarks to make in the 
next chapter, under the head of " Convulsive Tremor." 

It has been urged by some writers that migraine is a modified epi- 
lepsy. Dr. Hughlings Jackson would certainly regard such cases as 
those of Sir John Herschel, the astronomer-royal, the late Sir C. Wheat- 
stone, Dr. Hubert Airy, and, going farther back, those of Dr. Parry 
and Dr. Wollaston, as genuine epilepsy. Dr. Latham, 1 in his very in- 
structive little book,. from which I cite these examples, quotes as fol- 
lows Sir John Herschel's account of the phenomena observed in his 
own case, in which there were present in his field of vision irregular 
fortification-like figures, the margins of which were colored : 

" In one attack in myself, which occurred while I was conversing 
with an acquaintance, I soon became painfully sensible that I had not 
the usual command of speech ; that my memory failed so much that I 
did not know what I had said or had attempted to say, and that I might 
be talking to another." 

Dr. Airy, who has also described his own case, says : 

" Sometimes the speech is affected, and the memory at the same 

1 " On Nervous or Sick Headache," Cambridge (England), 1873, p. 10 ; also, Philo- 
vophical Magazine, vol. xxx., p. 21. 



EPILEPSY. 691 

time. On one occasion the mouth was seen to be drawn to one 
side." 

In a young female who came under Dr. Latham's observation, and 
who had colored spectra, there was a tingling of the arm and the 
side of the tongue, and on the same side with the spectra. Her sister 
and father were affected in precisely the same way. In another case 
the patient complained of a feeling of pinching and scratching on that 
side of the face corresponding with the glimmering. 

In most of these cases these spectra and sensations were followed 
by headache of severe character, attended with nausea and vomiting. 

But, notwithstanding the resemblance to epilepsy which all these 
phenomena of migraine suggest, Dr. Latham asserts that it differs 
widely from that terrible disorder in that it never threatens life, is 
never associated with unconsciousness, and that he has never known 
it to pass into epilepsy. On the contrary, with advancing age the at- 
tacks, as a rule, become much less frequent. They cease generally after 
fifty or sixty, and in women, not uncommonly, at the change of life. 

Dr. Latham holds the view that migraine is an affection of the sym- 
pathetic system; that the ocular spectra are the result of an anaemic 
condition of the brain due to a tonic contraction of the arteries; and 
that the pain which subsequently appears is the result of arterial relax- 
ation and consequent cerebral congestion. 

In his most thorough and valuable work Dr. Liveing ' discusses the 
whole subject of migraine in all its relations; and, while admitting with 
Marshall Hall, Sieveking and others that very intimate relations exist 
between sick-headache and epilepsy, and adducing several examples in 
which epilepsy has occurred to persons who were in previous years sub- 
ject to the former affection, nevertheless regards such occurrences as 
quite exceptional, and as instances only of that occasional metamor- 
phosis of neuroses so often witnessed. 

That migraine is an affection of the vaso-motor system is rendered 
very probable by the observations of Mollendorff, 2 who reaches the con- 
clusion that it is the consequence of arterial hyperasmia. He found 
that ophthalmoscopic examination of the eye of the affected side re- 
vealed the existence of dilatation of the arteria centralis retinas as well 
as of the choroidal vessels and of a bright-scarlet color of the fundus, 
while on the other side the vessels were normal, and the fundus, of .its 
usual dark-red color. 

This theory is adopted by Dr. Bergen 3 in a recent elaborate paper. 
It is the very opposite to that proposed by Dr. Bois-Reymond, accord- 

1 " On Megrim, Sick-headache, and some Allied Disorders, a Contribution to the Pa- 
thology of Nerve-Storms," London, 1873. 

2 "Ueber Hemicrania," Archiv. fur pathologische Anatomie, Band xl., p. 385. 

8 " On the Pathogenesis of Hemicrania," translation from the German by Dr. H. 
Gradle, in the Chicago Journal of Nervous and Mental Diseases, vol. i., 1874, p. 296. 



692 CEREBRO-SPINAL DISEASES. 

ing to which migraine is due to a tetanic contraction of the cerebral 
arteries. Neither of these authors regards migraine as a form of epi- 
lepsy. 

My experience with sick-headache has been quite extensive. I have 
frequently witnessed cases in which there were chromatic ocular spectra 
such as those described by Latham, Sieveking, and others, but I have 
never perceived anything more in the most marked forms of the affec- 
tion than a resemblance to some of the phenomena of the epileptic 
attack. One very noticeable difference is as regards the effect upcn 
the mind. In epilepsy the slightest and most transient seizures gener- 
ally impair, after a time, the mental faculties, especially the memory, 
while in migraine, no matter how severe or how frequent may be the 
attacks, the mind in all its parts retains its full vigor. 

There seems to be little or no doubt, therefore, that epilepsy is 
the result of cerebral irritation, which finally culminates in a sudden 
discharge of nerve-force. The seat of the discharge may be either in 
the cortex or in the medulla oblongata. There is some evidence, how- 
ever, which tends to show that even where the primary irritation is 
cortical the spasms are the result of the reflection of this irritation to 
the " epileptic centre " in the medulla. 

Treatment. — The treatment of epilepsy rests almost solely on ex- 
perience. To attempt the consideration of all the means which have 
been employed would be a fruitless task, even though it were possible. 
I shall therefore content myself with detailing the measures which I 
have found most useful. 

Among medical remedies the bromides stand preeminent, and should 
be thoroughly tried first in every case. The bromide of potassium, 
sodium, or calcium may be used. Of these, the bromide of sodium is 
the most advantageous in the majority of cases. Its taste — that of 
common salt — is not unpleasant, and it agrees better with the digestive 
system than the potassium compound. The bromide of calcium de- 
ranges the system still less, but its taste is not so pleasant, and it is 
much more expensive. Whichever one is preferred, the dose for an 
adult in ordinary cases and in the beginning of the treatment is fifteen 
grains three times a day in solution. 

It must be clearly understood that the bromide, if successful in 
arresting the convulsions, must be taken for a long time, in order to 
increase the probability of a cure. I never discontinue it under two 
years, and sometimes persevere with it still longer, if in the mean time 
there have been attacks of vertigo, aurse, or other epileptoid manifesta- 
tions. 

After the initial doses have been given for about two months, if 
there are no symptoms indicating extreme bromism, or if there has been 
no paroxysm, I increase the doses by cne-half. If there have been 
paroxysms in the mean time, I increase one-half after each paroxysm, 



EPILEPSY. 693 

until they are arrested, or until I am satisfied that the bromide is ineffi- 
cacious or injurious. I have sometimes been compelled to carry it to 
the extent of nearly two hundred grains a day, and to continue it at 
/ that quantity for eight or ten days. When the system is thoroughly 
V under the influence of the remedy and the convulsions have ceased, the 
/ X^doses may be reduced; but they should not be discontinued. 

The bromides are less efficacious in the nocturnal variety of epilep- 
tic seizures, and in those which consist mainly of loss of consciousness, 
than in the diurnal and strongly convulsive kinds. In the former, 
sometimes, they increase the number and severity of the attacks, and 
in such cases should of course be at once discontinued. 

A point connected with their action must not be overlooked, and 
that is, the cachexia which so generally attends their administration in 
large doses. In a memoir, 1 published over six years ago, and which has 
been cited in another connection, I brought forward several cases in 
which this cachexia had been produced. Greatly-increased experience 
has convinced me that, though in general it never causes any perma- 
nently ill effects, frequently great constitutional disturbance is in- 
duced. In three cases large carbuncles were caused, in a few I have 
been obliged to suspend for a time the administration of the medicine, 
and in two cases death resulted, in one from the patient taking larger 
doses than were prescribed, and continuing them while not under my 
immediate care, and in the other from the supervention of pneumonia 
while ander the full iufluence of the remedy. 

But, I am very sure that the bromic cachexia is favorable to the eradi- 
cation of the epileptic tendency, and I therefore endeavor to produce it 
as soon as possible. It appears in many cases to alter the whole organ- 
ism of the patient to such an extent as to leave him, when it disap- 
pears, with his nutritive processes and his proclivities so modified that 
epilepsy is no longer possible. The physician will require all his firm- 
ness and courage to persevere in those cases in which the bromism is 
extreme, but he should not yield unless the phenomena are so intense 
and the strength of the patient so greatly reduced as to excite his 
gravest apprehensions. 

The phenomena indicative of bromism will be given further on under 
the head of toxic affections of the nervous system. It may be, however, 
mentioned here that in the peculiar faculty possessed by the bromides 
of lessening the reflex excitability of the pharynx we have a ready 
means of ascertaining the extent to which the system is under the ac- 
tion of the remedy. If the handle of a spoon be pressed gently against 
the posterior wall of the pharynx of a healthy person, slight nausea and 
efforts to vomit are at once excited ; but, if such a person be subse- 
quently brought fully under the influence of any one of the bromides, 

1 " On some of the Effects of the Bromide of Potassium when administered in Large 
Doses," Journal of Psychological Medicine, January, 1869, p. 46. 



694 CEREBRO-SPINAL DISEASES. 

the irritability of that part is destroyed, so that nausea or vomiting is 
no longer excited by pressure. 

Herpin ' several years ago called attention to the salts of zinc in the 
treatment of epilepsy. He preferred the oxide, and for a long time I 
made extensive use of this preparation in the treatment of the disease 
in question. Latterly, however, I have used the lactate, and still more 
recently the bromide, with very definitely beneficial results. It is best 
administered in the form of a sirup — my formula is : $ . Zinci bromidi, 
3 j ; syrupus simplicis, § j. M. ft. sol. — which may be given in doses of 
ten drops gradually increased to thirty or more three times a day. It 
should be given largely diluted, as being the less apt to excite nausea. 

In several cases the bromide of zinc has proved exceedingly effica- 
cious thus far in arresting the paroxysms where other bromides had 
failed. Bromism is not an attendant on its administration, and yet it 
is quite probable that the bromine of the compound exercises consid- 
erable curative influence. I have given it as long a time as six months 
consecutively, without producing cachexia, and to the extent in some 
cases of forty grains a day. 

A troublesome feature which often attends the administration of the 
bromides — except the zinc compound — is the cutaneous eruption. 
Arsenic has been said to obviate the tendency to this complication, and 
to cure it where already present. In a few cases I have seen the use of 
the drug — four or five drops of Fowler's solution with each dose of the 
bromide — prove serviceable ; but in the majority of cases it has ap- 
peared to be inefficacious. Owing to the supervention of carbuncles 
with a strong predisposition to gangrene of the skin, I have been 
obliged in several cases to discontinue the bromide of potassium. The 
calcium compound is, I think, not so liable as those of potassium, 
sodium, or ammonium, to cause this trouble. 

In the nocturnal form of epilepsy strychnia is sometimes remarkably 
efficacious. It may be given in the beginning in the dose of the thir- 
tieth of a grain three times a day gradually increased. A good for- 
mula for its administration is : Ifc Strychnia sulph., gr. ij ; aqua dest., 
| j. M. ft. sol. Dose, eight drops three times a day for the first two 
weeks, then nine drops for the next two weeks, increasing a drop every 
two weeks for a year, and perhaps longer. 

Strychnia is also said to be useful in epilepsy of stomachal origin — 
that is, cases produced by gastric derangement. 

The nitrite of amyl, first proposed and used in epilepsy by Dr. Weir 
Mitchell, is certainly beneficial in arresting the paroxysm, when there 
is an aura sufficiently pronounced and slow to give the patient the time 
to employ it. Five to ten drops may be inhaled from a handkerchief 
with safety, and generally with success. As there is generally not time 
to pour it out, this quantity should always be kept on the person in a 
1 "Du pronostic et du traitement curatif de l'epilepsie," Paris, 1852. 



EPILEPSY. 695 

glass-stoppered vial ready for use at a moment's notice. Dr. McBride, 
of this city, has had made little hollow thin glass beads containing the 
proper quantity of the nitrite of amyl, and when the patient experi- 
ences the warning, one of these is crushed in a handkerchief and the 
vapor inhaled through the mouth. 

Dr. Crichton Browne ' has not only used the nitrite of amyl in pre- 
venting individual paroxysms, but has given it with advantage with 
the view of breaking up the status epilepticus — a condition in which the 
fits succeed each other with scarcely an intermission, the patient being 
unconscious during such intervals as occur. The results of his expe- 
rience are such as to convince him that it will be found invaluable in 
many cases, not only in postponing the paroxysm, but altogether pre- 
venting epileptic seizures. 

It may be stated that the effect of the nitrite when inhaled is to ac- 
celerate the action of the heart, to make the face red, and to cause a 
feeling of fullness in the head, and a sensation as if pins and needles 
were sticking into the skin of the face, neck, and chest. These phe- 
nomena disappear in a few moments. 

Within the last few years I have used the nitrite of amyl internally 
with, in some cases, decided benefit. It may be given in doses of from 
half a drop up to three or four, gradually increased, if necessary, and 
should be continued for a long time. A good formula is : fy . Amyl 
nit., itjj x ; alcoholis, tt# xc. M. ft. sol. Dose, from five to twenty 
or thirty drops a day. I usually begin with five drops on a lump of 
sugar, morning, afternoon, and bedtime, increasing the doses one drop 
every week so long as it continues to control the disease. 

Several cases of epileptiform seizures clearly due to syphilitic infec- 
tion have been under my charge, and have been treated with benefit by 
the bromides in conjunction with the iodide of potassium. In five of 
these, cures are known to have been effected. 

As regards other medicinal remedies for epilepsy, I have but little 
to say. Belladonna has never in my hands produced the least good 
effect, neither has the nitrate of silver, nor indigo, nor cotyledon um- 
bilicus, nor digitalis, nor any of the salts of copper. The same may be 
said of a hundred other substances less favorably known. Hydrate of 
chloral in three cases mitigated the frequency of the paroxysms, but 
only for a short time. Calabar bean was slightly beneficial in one case. 
Borax, after a very full trial, absolutely failed. 

But the whole treatment of epilepsy is not confined to drugs. Sur- 
gical and hygienic measures are often in the highest degree beneficial, 
and the latter should be brought into action in every case. 

Of the surgical means the excision of any cicatrix which, by entan- 
gling a nerve, may be a source of reflex irritation, is occasionally a 

1 " Nitrite of Amyl in Epilepsy," " West Riding Lunatic Asylum Medical Reports," 
vol. iii., 1873, p. 151. 



696 CEREBRO-SPINAL DISEASES. 

useful measure. This point has been brought forward in an inter- 
esting memoir by Dr. F. D. Lente, 1 in connection with cicatrices of 
the scalp, but the like reasoning and action are applicable to cica- 
trices existing in any other part of the body from which an aura 
appears to start. 

In injuries of the skull, followed by epilepsy, trephining may be of 
great service. It has been aptly said that no blow upon the head is 
slight enough to be despised, and, so far as epilepsy is concerned, this 
is preeminently true. I have, during the past five years, trephined 
twenty-three times for epilepsy which was apparently due to cranial 
injuries. In seven of these the fits ceased, and in two of the seven 
cases there was neither fracture nor depression. Of the remaining 
sixteen cases there was no cranial injury to be found in three ; and in 
thirteen, though there was such injury, the operation proved unsuc- 
cessful, though beneficial results in lessening the frequency of the 
attacks were obtained in the majority. In one of them the fits did not 
recur for over a year. The fact that in two of the successful cases 
no fracture or depression was found is a strong point in favor of Dr. 
Lente's view that epilepsy is sometimes the result of a cicatrix of the 
scalp, for, in both, the incisions in the scalp, as in all the others, were 
made so as to include the scalp-wound. 

In those cases in which the spasms are confined to one side of the 
body, to one leg, to one arm, or to one side of the face, trephining 
over the motor centre involved, and the removal of the tumor or the 
excision of the diseased area of cortex, should be insisted upon as soon 
as the precise character of the disease can be ascertained. 

As the result of my experience, I am decidedly of the opinion that, 
in all cases of epilepsy in which there is injury of the skull or scalp, 
trephining or excision of the cicatrix should be performed, as may be 
proper. 

In some cases counter-irritation to the nape of the neck is decidedly 
beneficial. It may consist either of a seton, which may be left in for 
several months, or the repeated application of the actual cautery. 
Counter-irritation is especially indicated in those cases in which the 
tongue is bitten, and instances in which internal remedies have failed 
till they were supplemented by this means are not uncommon. 

The hygienic management of the patient is important. A large por- 
tion of the day should be passed in the open air ; bodily exercise should 
be regular, but not excessive ; the food should be nutritious, but neither 
exciting nor indigestible. The importance of avoiding every aliment- 
ary substance calculated to cause gastric or intestinal irritation cannot 
be over-estimated. I have frequently seen paroxysms directly caused 

1 "Neuralgia and other Neuroses arising from Cicatrices of the Scalp, and their 
Surgical Treatment," " Transactions of the American Neurological Association," vol i., 
New York, 1875, p. 157. 



EPILEPSY. 697 

by nuts, dried fruits, pastry, heavy and badly-baked bread, excess in 
the use of alcoholic liquors, confectionery, and the like. And a diet 
consisting mainly of farinaceous substances is certainly preferable to 
one in which meat forms the larger part. I have in three cases effected 
entire cures by confining the patients for several months to a diet con- 
sisting at first of skim-milk, to which after a time a little bread was 
added. The bowels must be kept regular. Baths should be frequently 
taken, but should not be so cold as to cause severe shock or physical 
depression. Turkish baths, I am inclined to think, are useful in many 
cases, particularly in those occurring in persons of full and gross habit 
of body. 

Overheated and ill-ventilated apartments should be avoided. The 
clothing should be warm in winter and cool in summer. The mind 
should not be overtasked, and the emotions must not be unduly excited. 

Individual attacks may sometimes be prevented by other means 
than the nitrite of amyl. One gentleman under my charge assures me 
. that he can often dissipate the premonitary symptoms, and thus stop 
the development of the paroxysm, by a strong exertion of the will. 
Another can arrest them sometimes by changing the position of his 
body. If standing, he lies down ; if lying down, he rises suddenly and 
paces the room violently. Another stops them by putting salt in his 
mouth, and two can frequently prevent them by tightening straps which 
I have instructed them to keep constantly around the wrist. In all 
these cases there is an aura, and in the two latter it appears to start 
from the hand. 

But, before resorting to any specific treatment for epilepsy, diligent 
search should be made for the cause, and this should be removed, if 
possible, without the least delay. Often an eccentric irritation, such 
as worms in the intestinal canal, implication of a nerve in an injury, 
disorders of menstruation, etc., can be discovered, without the removal 
of which a permanent cure is impossible. In several of the cases cited, 
success in the treatment was in a great measure due to acting on this 
principle. 

The treatment during the paroxysm remains to be considered. It 
is simple, and, beyond a few obvious measures, consists in letting the 
patient alone. The head should be elevated, the collar and cravat 
loosened, a piece of soft wood put between the teeth so as to prevent 
injury to the tongue, and the patient so placed that he cannot fall or 
otherwise injure himself in his struggles. During the subsequent 
stupor he should be kept quiet. Bloodletting is never necessary, 
although it is recommended as proper in certain cases by Jaccoud, 



698 CEREBRO-SPINAL DISEASES. 

CHAPTER III. 

CONVULSIVE TREMOR. 

Under the designation of convulsive tremor, I propose to include 
all those cases of non-rhythmical tremor or clonic convulsive move- 
ments which are unattended with loss of consciousness, but which, 
nevertheless, are paroxysmal in character. 

As the affection has not yet found its way into the systematic trea- 
tises, I shall, as in the matter of spinal irritation, devote a few words 
to its history, and, in so doing, shall draw largely from a paper of my 
own on the subject, published over eight years ago, 1 and from a clinical 
lecture 2 delivered to the class at the Bellevue Hospital Medical College 
in the winter of 1871-'72. 

A few years ago Friedreich 3 reported a case of what he termed 
paramyoclonus multiplex, which differs in no essential particular from 
the cases described in this chapter. There is a tendency on the part 
of some observers to regard paramyoclonus multiplex and convulsive 
tremor as two distinct affections, without there being, in my opinion, 
any just grounds for so doing. 

History and Symptoms. — In the year 1822 Dr. Pritchard, 4 under the 
name of convulsive tremor, gave an account of two cases, presenting 
somewhat similar features to the one before us. His attention was 
first directed to the subject by noticing that, in some epileptic patients 
who had come under his observation, fits of tremor occurred in the in- 
tervals between the paroxysms and even appeared to take the place of 
the ordinary seizure. He then noticed several cases in which there 
were no epileptic attacks, but in which there were violent clonic spasms 
of the muscles, accompanied with severe pain in the head and profuse 
perspiration. Dr. Pritchard states that, previous to his observations, 
the affection had not attracted much attention ; but he cites a case 
from Tulpius of a young unmarried woman, of a pale complexion and 
phlegmatic temperament, who was afflicted during three years with 
what was called the shaking-palsy, which did not affect her constantly, 
but came on in periodical fits; each paroxysm lasted nearly two hours, 
and was accompanied by hoarseness and loss of voice, the consciousness 
being unimpaired. 

He also refers to other cases quoted by Sauvages from Bonetus, in 
which the symptoms were very similar, consisting of convulsive tremor, 
attended with headache and vertigo. This disorder was fatal in a few 
days, and after death a parasite was found in the brain. In this con- 

1 "On Convulsive Tremor," New York Medical Journal, June, 1867, p. 185. 

2 " Clinical Lectures on Diseases of the Nervous System," New York, 18*74, p. 164. 

3 VirchovPs Archives, Bd. lxxxvi., p. 421. 

4 "A Treatise on Diseases of the Nervous System," London, 1822, p. 393. 



CONVULSIVE TREMOR. 6D9 

nection it is interesting to recall the fact that the sheep is subject to a 
somewhat similar train of symptoms, due to the presence of an ento- 
zoon in the brain. 

Dr. Pritchard then relates his own cases, of which the following ac- 
count is an abstract: 

John Pugh, a carpenter, of meagre habit, low stature, and dark 
hair, aged fifty, was admitted into St. Peter's Hospital March 1, 1820. 
About a month previously he had suffered from tonsillitis and subse- 
quently had some difficulty of breathing, which was supposed to be 
asthmatic. He had complained of headache for some time. On the 
23d of February he was attacked with a violent tremor, which con- 
tinued for two or three hours, and then went off after he had taken an 
emetic. It recurred on the following day at the same time, and on 
every succeeding day about the same hour. At the time of his admis- 
sion he was laboring under a paroxysm. 

On first looking at the man, Dr. Pritchard supposed him to be in 
the cold stage of intermittent fever, but on closer and more careful ex- 
amination his affection was seen to be very different. All the muscles 
of the upper extremities, including those connected with the ribs, clav- 
icle, and scapula, were constantly agitated by a convulsive movement 
which was almost entirely confined to them. The lower extremities 
were quite free from disorder. The man was perfectly conscious, and 
able to answer any question distinctly. His pulse was quick and ap- 
parently irregular. Owing to the constant agitation of the tendons it 
was impossible to arrive at certainty on this latter point. The skin 
was warm, and there was no sensation of chilliness. The upper part of 
the body was in a state of profuse perspiration. He complained of ver- 
tigo and headache. 

Bloodletting was ordered; a large orifice was made, and the blood 
allowed to flow till thirty-eight ounces had escaped, when syncope en- 
sued. When half the above quantity had passed, the tremor became 
more general and severe. The gluteal muscles were so greatly con- 
vulsed that by their action the patient was thrown up from his seat 
with the motion of a man sitting on a trotting horse. When he became 
sick and faint, the arm was tied up and he was laid upon a bed. The 
tremor immediately ceased, except some slight and partial quivering. 

He was then strongly purged, and this operation was continued 
every night. On the 5th, at 11 A. m., the tremor returned. Cold effu- 
sion was directed ; as soon as the cold water was thrown over him the 
tremor ceased. 

On the 9th there had been no return of the tremor. Calomel and 
sulphate of magnesia were now prescribed and on the 11th the tremox 
returned, lasting, however, but about twenty minutes. From this time 
he was free from the affection, but, as might have been expected, when 
the character of the treatment is considered, he fell into a state of de- 



700 CEREBROSPINAL DISEASES. 

bility. There were loss of appetite, cough, expectoration, and inflam- 
mation of the vein, ensuing from the bleeding. 

In the next case the paroxysms of tremor were the most remarkable 
feature, but there were also stupor and delirium. 

John Jones, a seafaring man, aged twenty -five, was brought to the 
hospital March 11, 1819, under a warrant of lunacy ; was in the habit 
of drinking spirituous liquors. Three weeks previously he was seized 
with rigors, attended with coldness, and followed by heat, headache, 
and wandering pains in the limbs. The symptoms ushered in a state of 
stupor and delirium, during which his countenance became distorted, 
the e}~es rolled, the muscles of the face were slightly convulsed, and 
the body was generally agitated. After a time all these symptoms 
subsided and he became perfectly rational, but seemed a little stupid, as 
if roused from a sleep. The paroxysms returned at uncertain intervals 
and with the same succession of symptoms. He was bled and purged, 
and finally brought to the hospital. 

On admission he was in a state of delirium. He rolled his head 
about and was in constant motion. The temporal arteries beat rapidly 
and forcibly; the scalp was hot, the feet cold; face flushed and tongue 
a little furred. 

His head was shaved and covered with cold wet pads, his feet were 
immersed in hot water, twenty leeches were then applied to the head, 
and calomel and tartar-emetic with cathartic draught administered. 

The next day he was rational, but, as he complained of pain in the 
head and in the region of the liver, and as his pulse was 130, full and 
jerking, he was bled to the extent of eight ounces ; syncope followed. 
Twelve leeches and a blister were then applied to the right hypo- 
chondriac region, and calomel, cathartic draught, and low diet ordered. 

Notwithstanding the treatment, he continued to survive, and in the 
evening had two returns of the tremor followed by the usual symptoms. 

On the 14th had several paroxysms, and was again freely purged ; 
was occasionally bled from the temporal artery, and often leeched freely. 
Nitrate of silver was subsequently administered, and on the 23d of June 
he was discharged cured. 

Dr. Pritchard states that he met with two other instances of parox- 
ysms of tremor unaccompanied with spasm, and occurring in persons 
who had suffered from an attack of paralysis. 

Evidently Dr. Pritchard has embraced two or three separate affec- 
tions under the designation of convulsive tremor. The first case I have 
quoted from him appears to be a distinct and not previously-described 
disorder ; the second case was probably one of cerebral congestion or 
aborted epilepsy; and those which he states he had seen as the sequence 
of paralysis were doubtless to be classed under some one or other of the 
forms of sclerosis of the brain and spinal cord. The first case alone is 
to be regarded as one of convulsive tremor, as described in this chapter. 



CONVULSIVE TREMOR. 701 

In his very excellent treatise on the shaking-palsy, Parkinson, 1 in 
calling attention to the fact that several diseases characterized by tre- 
mor have been confounded with paralysis agitans, quotes the following 
case from Dr. Kirkland : 

" Mary Ford, of a sanguineous and robust constitution, had an invol- 
untary motion of her right arm, occasioned by a fright, which first 
brought on convulsion-fits and most excruciating pain in the stomach, 
which vanished on a sudden, and her right arm was instantaneously 
flung into an involuntary and perpetual motion like the swing of a pen- 
dulum, raising the hand at every vibration higher than the head ; but, 
if by any means whatever it was stopped, the pain in her stomach came 
on again, and convulsion-fits were the certain consequence, which went 
off when the vibration of her hand returned." 

Parkinson also quotes another case from the same source, resulting 
apparently from worms, and which is thus described : 

" A poor boy, about twelve or thirteen years of age, was seized with 
a shaking-palsy. His legs became useless, and, together with his head 
and hands, were in continual agitation ; after many weeks' trial of va- 
rious remedies, my assistance was desired. His bowels being cleared, I 
ordered him a grain of opium a day in the gum-pill ; and in three or four 
days the shaking had nearly left him. By pursuing this plan, the medi- 
cine proving a vermifuge, he could soon walk, and was restored to per- 
fect health. 

Toulmouche, 2 in a paper which is very suggestive in the light of re- 
cent contributions to neurological pathology, cites a case which was 
evidently one of convulsive tremor : 

"A woman, whose respiration was convulsive, presented from time 
to time the following condition : Her nostrils were strongly dilated, the 
angles of the mouth drawn down, the shoulders and chest spasmodical- 
ly elevated, the inspiration strong and deep, the sterno-cleido-mastoid 
muscles were powerfully contracted. During these paroxysms, which 
lasted several minutes, the patient was deprived of the faculty of speech 
and threatened with suffocation. Nevertheless, she could, if so direct- 
ed, move the head, the shoulders, and the muscles of the face, although 
the spasm continued. ... In another case the affection was almost en- 
tirely confined to the sterno-cleido-mastoid muscle. The patient could 
turn the head in either direction, but gradually it moved from right to 
left, without her ability to control its action, so that the right ear al- 
most rested upon the sternum. The other muscles of the shoulder con- 
tracted at the same time. He likewise reports another case in which 
the head was almost continually in motion, the patient executing twen- 

1 "Essay on the Shaking-Palsy," London, 1817, p. 29. 

2 " Observations de quelques fonctions involuntaires des appareils de la locomotion, 
et de la prehension," "Memoires de l'acadeniie royale de medecine," tome deuxieme^ 
Paris, 1833. 



702 CEREBROSPINAL DISEASES. 

ty-two rotations in a minute ; the movement was due to the alternate 
contraction of the sterno-cleido-mastoid and splenius muscles of each 
side ; respiration was not obstructed. The movements diminished and 
finally ceased after two or three attacks of haemoptysis. 

" The conclusions which the author draws from his own cases, and 
those w r hich he cites from other authorities, are mainly interesting in 
relation to his theory of the pathology. They are — 

" 1. That there exist, for the movements of the different groups of 
muscles, different central motor forces. 

" 2. That the cerebellum only presides over the coordination of those 
complex movements which are necessary to the different acts of stand- 
ing and locomotion, and not at all over those that regulate the more sim- 
ple movements of the trunk and the members. 

"3. That this nerve-centre supplies to vertebrate animals the power 
to maintain themselves in equilibrium and to exercise locomotion. 

" 4. That, if, in the species of neurosis I have described, the sensa- 
tion and the intellectual faculties experience no change, this fact is due 
to the circumstance that the lesions of the cerebellum have not yet in- 
volved the tubercula quadrigemina. That these last-named organs are 
in a state of dependence upon the brain ; since in the normal state ani- 
mals move through the impulsion of various motives of which the brain 
is the seat. 

" 5. That finally a number of affections called nervous, consisting in 
the most erratic derangements of the muscular functions, such as an 
irresistible tendency to go backward or to advance without rational 
motive, to leap, to perform other disorderly movements, constitute only 
a species of insanity or aberration of the locomotor functions depend- 
ing on an affection either organic or functional of the cerebellum." 

I have quoted the conclusions of Toulmouche in full more as evi- 
dence of the fact that he was disposed to locate the seat of these trou- 
bles in the cerebellum, than as intending to endorse his collateral 
hypotheses. At one time I also held the opinion that the seat of con- 
vulsive tremor was in the cerebellum, but I have for some time had a 
different idea on the subject. 

Up to the publication of my own paper, in 1867, there had been no 
attempt made to define accurately the features of the disease under no- 
tice. My description of the affection was based upon three cases. They 
were as follows : 

Case I. — J. S., a gentleman, aged thirty-five, single, and engaged 
in mercantile pursuits, consulted me on March, 14, 1867, for an affec- 
tion which, as he said, "was driving him mad." Ordinarily he had 
nothing to complain of on the score of health. His appetite was good, 
and all his functions were performed with regularity ; but two or three 
times during the course of the day he would be seized with severe and 
uncontrollable muscular tremor, involving his head and all the muscles 



CONVULSIVE TREMOR. 703 

of the trunk and arms. At the same time there would be neadache and 
an intense feeling of anxiety. There was no loss of consciousness, not 
even for an instant, or inability to walk or to direct any muscle, and no 
confusion of thought. After the paroxysm had lasted fifteen or twenty 
minutes it gradually passed off, leaving him in a profuse perspira- 
tion. 

While he was sitting in my library an attack came on. He was 
seized with as much suddenness as though he were struck with an epi- 
leptic fit. His head shook violently, the muscles of his face were con- 
vulsed, his arms and hands trembled, and his gluteal muscles contracted 
so powerfully as to cause him to move convulsively up and down on his 
chair. His lower extremities were altogether free from spasm or con- 
vulsion. Upon putting my hand on his wrist, I found that every ten- 
don was in action, and in the arm, hand, neck, and face, the vibration 
of the muscular fibres could be distinctly seen and felt. I thought the 
action was greater on the left than on the right side. 

The thermometer applied to the axilla marked 101° Fahr., and the 
sesthesiometer showed an increased sensibility of the skin of the face, 
neck, hands, and all the upper parts of the body I examined. The res- 
piration was quickened, and the pulse was increased from 80 to 95 per 
minute. 

During the continuance of the paroxysm he conversed rationally 
but with some difficulty, owing to the action of the muscles of the neck, 
mouth, and chest. The pupils contracted briskly under the influence 
of light, and dilated when it was shut off. Several times he rose from 
his chair and paced the room; his movements were perfectly well made. 
There was a little headache, confined to the occipital region, and a slight 
but persistent vertigo. 

I desired him to perform a few movements with his hands, such as 
buttoning his waistcoat. He had no great difficulty in carrying his 
hands to the buttons, but it was impossible for him to seize them, and 
the more his efforts were directed to this end the more difficult it was for 
him to accomplish it. The trouble was not in loss of strength, for, when I 
asked him to grasp my hand, he did it with great force, but the tremor 
was so constant that he could not keep the ends of his fingers at any 
one point. 

After the paroxysm had lasted about fifteen minutes it began to 
subside, and in ten minutes more had entirely passed away. The ther- 
mometer in the axilla now marked but 98° Fahr., and the hypersesthesia 
had entirely disappeared, leaving the sensibility of the skin natural. 
The respiration and pulse became normal in frequency. 

Upon questioning this gentleman, I ascertained that he had in- 
dulged to excess in venereal pleasures, and that the first attack of 
tremor had begun during sexual intercourse. He said that, just as the 
orgasm was approaching its height, he had experienced a severe pain 



704 CEREBROSPINAL DISEASES. 

in the back of his head, accompanied with tremor. That, notwith- 
standing, he had completed the act, but felt very greatly debilitated 
after it ; the tremor continued for a few minutes, and then passed off. 
This was about four months before I saw him. Since the beginning of 
his disease he had entirely abstained from all sexual indulgence, but his 
tremors had not left him for a night or day. In consequence he was 
low-spirited, and apprehensive of losing his reason. 

Case II. — The second case was that of a young lady, aged twenty- 
one, who was sent to me March 21, 1867, by Dr. C. F. Taylor, to whom 
she had gone to be treated for lateral curvature of the spine. In addition 
to this trouble she had for four years been afflicted with a disorder, cer- 
tainly very singular in its characteristics, and for which she had been 
treated by many physicians of many systems of practice. The chief 
and most distressing feature was a spasmodic action of the diaphragm 
coming on every ten or fifteen minutes, producing convulsive respira- 
tion, a feeling of impending suffocation, and great mental anxiety. 
The paroxysms lasted four or five minutes, and then passed off with a 
long, deep-drawn sigh. None of the respiratory muscles but the dia- 
phragm were convulsed. By placing the hands over the abdomen this 
muscle could be distinctly felt in a state of rapid and irregular action. 
In the intervals of the diaphragmatic paroxysms, there were frequent 
tremors of the arms, legs, and head. There was almost constant head- 
ache extending across the crown to the cerebellar region. There was 
no fever or increased temperature, but great hyperesthesia of the 
whole surface of the body. The menstrual function was normal in 
every respect, and there was no evidence of hysteria. Her appetite 
was bad, and what she did eat was not of a very nutritious character. 
Occasionally she was subject to fits of great mental and muscular ex- 
citement, during which she fought and bit all who came near her, but 
there was no mental aberration. She had never been subject to inter- 
mittent fever. 

In this case the convulsive tremor, though more prominently mani- 
fested in the diaphragm, was not confined to this muscle, for, as I have 
stated, when it was quiet the muscles of other parts of the body were 
in irregular but rapid action. There was not the entire cessation of 
tremor as exhibited in the first case, and the paroxysms were much less 
uniform and much less extensive in their character. In both cases the 
tremor was absent during sleep. 

Case III. — In a third case the patient was a young man aged twenty- 
five, and a clerk by occupation. He came under my care April 2, 1867, 
to be treated for obstinate headaches, with which he had been affected 
for several years. On an average he had an attack twice a week of so 
severe a character as to unfit him for all occupation and to confine him 
to bed. The pain was limited to the back part of the head, and was 
exceedingly sharp and lancinating; vertigo and an indescribable twist- 



CONVULSIVE TREMOR. 705 

ing sensation within the cranium accompanied the attack. In addition 
there was convulsive tremor of the muscles of the head, face, and neck, 
occurring in paroxysms at intervals while the headache lasted. There 
was no loss of consciousness and no confusion of thought. There were, 
however, great physical prostration, and an indisposition to make any 
mental exertion. 

In his youth he had, as he informed me, practised masturbation to 
excess, and since attaining to manhood had indulged freely with women, 
He was also addicted to the abuse of alcoholic liquors. He was thiu, 
pale, and of deficient vital power. His digestive system was deranged, 
his appetite bad, his pulse weak and frequent. There was no disease 
of the lungs or heart. He had had gonorrhoea and stricture, but had 
never contracted a chancre. 

He had been under the charge of several physicians, but had never 
been able to subject himself to the regimen and restrictions in his 
habits of life which they recommended. Latterly he had undertaken to 
treat himself, and had done so mainly by inhalation of chloroform. 

This patient would not abstain from debauchery of all kinds, and 1 
dismissed him. 

Case IV. — A fourth case formed the subject of a clinical lecture 
which I delivered three years since before the class of the Bellevue 
Hospital Medical College. The patient, a young man, aged about twen- 
ty-one, was well nourished, of general healthy appearance, and by oc- 
cupation a farmer. 

At periods varying from a few weeks to several months, he was sub- 
ject to violent convulsive movements in almost all the muscles of the 
body, and unattended, except in one instance, by loss of consciousness. 
The paroxysms lasted several hours, and during their continuance the 
patient, owing to the violent jactitations into which his limbs were 
thrown, was totally unable to execute voluntary movements. He was 
even unable to stand without support, and could not guide either his 
hands or feet. The muscles of speech were likewise affected, and he 
was consequently unable to articulate distinctly the words he might 
attempt to utter. "While all this was going on, his body was bathed in 
cold perspiration, and the circulation was accelerated. The respiration 
was increased in frequency, and there was well-marked and persistent 
pain in the back of the head and nape of the neck. He was very posi- 
tive that, except in the one instance to which reference has been made, 
he had never lost consciousness during a paroxysm, but had always 
been possessed of his full reasoning faculties. 

On the occasion of loss of consciousness the paroxysm had lasted 
several hours ; he was in consequence very much exhausted, and there- 
fore he may have been suffering from simple syncope, still it is possible 
the attack in question was epileptic. When he came under my noticej 
he had been affected for about six years. 
46 



706 CEREBROSPINAL DISEASES. 

As he described his paroxysms, the muscles were affected very much 
as are those of a person suffering from chorea of very violent charac- 
ter. 

Case V. — A fifth case was that of a man thirty years of age, who, 
in November, 1875, came to my clinic for diseases of the nervous sys- 
tem at the University Medical College. At intervals through the day, 
as often as twenty or more times, he was seized with violent convulsive 
movements, tremulous in character, and mainly confined to the muscles 
of the trunk, neck, and upper extremities. As in the other cases, there 
was no. loss of consciousness, nor was there any other mental disturb- 
ance. He had no power of control over these paroxysms and no warn- 
ing of their approach. They were unattended with disturbances of the 
respiration, circulation, or sensibility. The duration rarely exceeded 
ten seconds, and was generally shorter than this. It was impossible to 
say where the convulsive movements originated. They came more as 
an explosion than as a gradually-developed action. 

While the convulsion was at its height, he could always cut it short 
and prevent others for a time by smoking a pipe of tobacco, the requi- 
sites for which he kept constantly ready. He had been affected for 
seven years, but had in that time experienced an intermission of about 
six months. He had never had a paroxysm while asleep. 

Case VI. — This case was that of a lady from Ohio, who consulted 
me for paroxysms of convulsive tremor, coming on several times in the 
course of the week, and involving the upper and lower extremities and 
neck. There were also marked disturbances of the respiration and cir- 
culation, and pain in the nape of the neck. The movements consisted 
of rapid but limited flexions and extensions of the limbs and rotatory 
movements of the head. The duration of a paroxysm was rarely less 
than ten minutes, and sometimes was several hours. There was no 
mental disturbance or impairment of consciousness. The disease had 
existed for several years, and had proved unamenable to all medical 
treatment. After each seizure there was a very intense feeling of fa- 
tigue, but no tendency to sleep or stupor. No paroxysm had ever oc- 
curred during sleep. The general health was excellent, and the mind 
was active and strong. 

Several other cases similar in general features to the foregoing have 
been under my charge. 

From this history and description it will be seen that convulsive 
tremor is an affection characterized by paroxysms of clonic convulsions 
affecting the voluntary muscles and unattended by loss of conscious- 
ness or by mental aberration, though sometimes there is emotional dis- 
turbance. Vertigo and pain in the head are also occasional accompani- 
ments. 

Causes. — Nothing very definite is known relative to the etiology of 
the disease. In one of my cases it began during sexual intercourse ; 



CONVULSIVE TREMOR. 707 

tn another (Case V.) it ensued immediately after a sunstroke, the first 
paroxysm occurring while the patient was still in a comatose condition; 
in another (Case III.), sexual and alcoholic excesses appeared to be the 
cause. In none of the others could any approach to a relation of cause 
and effect be established. 

Diagnosis. — From epilepsy, convulsive tremor is distinguished by 
the absence of loss of consciousness. Many of the cases which Dr. 
Hughlings Jackson considers epileptic are, in my opinion, more prop- 
erly embraced under the present category. From chorea it differs in 
the facts that the muscular action is paroxysmal and not continuous, 
and that the movements are different in character, those of convulsive 
tremor being rapid and tremulous, while those of chorea are slower and 
more systematic. The paroxysmal nature of the actions serves to dis- 
tinguish it from athetosis, multiple cerebral sclerosis, multiple cerebro- 
spinal sclerosis, and paralysis agitans. From hysteria it is in uncom- 
plicated cases diagnosticated by the absence of other symptoms of the 
hysterical condition, by the fact that the convulsions are not marked 
by tonic spasms, and the circumstance that they have for each individual 
case a definite character. 

Prognosis. — The prognosis is generally favorable, the disease, in my 
experience, being quite amenable to medical treatment. All the cases 
under my care recovered except one in which the patient refused to 
submit to proper hygienic restraints, and in whom treatment was not 
therefore systematically pursued. 

Morbid Anatomy and Pathology. — In former papers I have stated 
my belief that convulsive tremor was an affection of the cerebellum, 
but in the light of the investigations of Fritsch and Hitzig, Nothnagel, 
Ferrier, and Bartholow, I am now disposed to consider it due to irrita- 
tion of nerve-centres in the cortical substance of the cerebrum, con- 
joined with a hyperaesthetic condition of the medulla oblongata and 
upper part of the spinal cord. And I am the more confirmed in this 
opinion by some recent experiments by which I have ascertained that 
a very similar disorder can be induced in dogs by the faradization of 
the parts mentioned. 

Ferrier 1 produced epileptiform convulsions in rabbits by faradizing 
the greater part of a hemisphere. In one of my own experiments I 
exposed both hemispheres and applied to each a piece of chamois-skin 
thoroughly moistened with water, and cut to fit the surface. The 
electrodes — metallic buttons — were, then placed one on each piece of cha- 
mois : skin, and moved lightly over the surfaces for a few seconds. The 
animal was then allowed to emerge from the anaesthetic condition, and 
immediately general convulsive movements ensued without loss of 
consciousness. The result was, therefore, similar to that obtained by 

1 " Experimental Researches in Cerebral Physiology and Pathology," " West Riding 
Lunatic Asylum Medical Reports," vol. iii., 1873, p. 30. 



708 CEREBRO-SPINAL DISEASES. 

Ferrier, but so far as I can judge the convulsive movements were more 
general, and there was no pleurothotonos as in his cases. The parox- 
ysm lasted about ten seconds, and was repeated, though not to the same 
degree of intensity, after an interval of three minutes. During the 
next half -hour there were repeated localized convulsive movements in 
various parts of the body. 

In another dog I exposed both hemispheres, and also the upper part 
of the spinal cord, as far down as the fourth cervical vertebra. A piece 
of wet chamois-skin was then laid upon the brain, and one electrode — a 
thin plate of copper — placed in contact with it, while the other — a thin 
copper wire doubled upon itself — was moved up and down upon the 
exposed spinal cord. During this operation the animal was in a 
state of general convulsion, the respiratory muscles, especially the dia- 
phragm, being involved. The current was passed in this manner for 
ten seconds. The animal was then allowed to recover consciousness. 
As soon as the effects of ether had measurably passed off, convulsive 
movements ensued throughout the body, the diaphragm being marked- 
ly affected with the other respiratory muscles, and the heart beating 
with great irregularity, both in regard to force and rhythm. 

In these experiments a Gaiffe's faradaic machine was employed, and 
the current was so feeble as barely to move the hammer and to be felt 
when the electrodes were applied to the tongue. 

I think with Dr. Hughlings Jackson that such convulsive movements 
are the result of " discharging lesions " of nerve-centres. The case of 
the patient to which I have referred under the head of epilepsy, in 
whom there was convulsive tremor of one side of the neck and face, 
induced by irritation applied to the skin of that side, shows, as well as 
others on record, that such instances may be developed into epilepsy 
under adequate circumstances, but, as there said, I cannot regard them 
as primarily epileptic. 

In another case — that of a young lady who has come under my care 
since the chapter on epilepsy was written, who is very excitable, has 
had two choreic periods, and once, certainly, an epileptic seizure — there 
are daily several attacks of convulsive tremor, in which the action 
starts from the right side of the neck, gradually invades the right side 
of the face, and eventually the muscles of the corresponding upper 
extremity. There is not for a moment the slightest impairment of con- 
sciousness. The face, however, is at first deathly pale, but soon be- 
comes flushed. There is no stupor, no mental confusion before, during, 
or after the attack. She laughs and talks during its continuance, and 
has a perfect recollection of every thing that takes place during the 
paroxysm. That such a case is very near to epilepsy is undoubted, but 
then congestion is very near to inflammation, and may exist for years 
without advancing to full development. 

There are certain morbid conditions usually classed as choreic, 



CONVULSIVE TREMOR. 709 

which have more affinity with convulsive tremor than with chorea, 
though, perhaps, they are, with even greater propriety, placed under the 
head of hysteria. These are the turnings, salaam-convulsions, jump- 
ings, etc. It is quite probable that the lesion causing those disorders 
is similar to that producing convulsive tremor. 

The morbid anatomy of the affection under notice is entirely a 
matter of supposition, and indeed there are not many data for forming 
an opinion relative to the essential nature of the structural alteration. 
So far as we can judge from a consideration of the phenomena, the seat 
is in the cortical substance of the brain, and in the medulla oblongata 
and upper part of the spinal cord. The disturbances of the respiration 
and circulation point to these latter organs as a part of the anatomical 
substratum. 

In those cases in which there are spasms localized in various parts 
of the face, neck, or extremities, it is probable that the lesion exists 
entirely in a limited part of the cortical substance constituting the 
motor centre for the region involved. 

Treatment. — In the first cases that came under my observation, I 
employed counter-irritation in the form of a seton inserted into the 
nape of the neck, large doses of the bromide of potassium, and the 
primary galvanic current. Iron and quinine were given in two cases to 
relieve the general anaemic condition which existed. These measures 
were entirely successful, except in the third case, in which the bromide 
of potassium produced no perceptible effect. The tincture of hyoscya- 
mus was substituted for it with good results, but all treatment was 
subsequently abandoned as stated. 

In the fourth case the patient was treated with gradually-increasing 
doses of strychnia, with the effect of causing a complete cure. A solu- 
tion of the sulphate of strychnia, consisting of two grains to the ounce 
of water, was administered in doses of ten drops three times a day, the 
doses being increased by one drop every day, till the physiological 
effects of the drug were obtained. A return to the original dose of ten 
drops was then directed, and an increase as before. From thirty to 
thirty-five drops were generally necessary to cause slight rigidity of the 
muscles of the legs and neck. The patient continued treatment for 
several months, and had no further spasms. 

In the fifth, sixth, and other cases, I have relied for internal treat- 
ment entirely on the bromide of zinc given in solution in gradually- 
increasing doses. In all of these the result has been entirely satisfac- 
tory. In the fifth case, no paroxysm ensued after the first day of treat- 
ment. Four weeks afterward, the patient presented himself at my 
clinic, and announced the complete cessation of all convulsive move- 
ments, and that he had resumed his work, which had been interrupted 
for several years. 

In the sixth case I administered the zinc, and in addition applied 



710 CEREBROSPINAL DISEASES. 

the actual cautery repeatedly to the nape of the neck. Only one 
paroxysm occurred after the treatment was begun, and tnat was in- 
duced by the excitement and irritation caused by the primary galvanic 
current applied to the spine. The patient, two months afterward, re- 
mained entirely well, though still continuing to take the zinc. 

In all the other cases, five in number, the bromide of zinc has suf- 
ficed to effect the cure. 

I have uniformly given it in solution, either in water or simple 
syrup, in the proportion of one drachm to the ounce. Of this mixture, 
ten drops were given three times a day for the first two weeks, then fif- 
teen drops three times a day for the next fortnight, and so on, increas- 
ing five drops for the doses of each subsequent two weeks. This course 
has been continued for from' three to six months, and then the doses 
are gradually reduced, except in Cases V. and VI., in which I shall 
continue them for a much longer period, and in two others which have 
been but for a short time under treatment. 



CHAPTER IV. 

CHOREA. 

Although it is quite certain that several distinct affections are in- 
cluded under the term " chorea," these are analogous to each other, 
and, as we know little about the essential anatomical features of these 
disorders, and as they are allied by their symptoms, it will be advisable, 
for the present, to consider them together. 

Symptoms. — Even in simple, typical, and uncomplicated cases of 
chorea, the symptoms exhibit great variety. They are connected 
mainly with the mind, with motility, and with sensibility, though, at 
the same time, the functions of organic life are generally more or less 
deranged. 

Among the earliest symptoms of chorea are those referable to dis- 
ordered brain-action. The character and disposition of the patient 
undergo a marked change, and there is, besides, from the first, a very 
decided impairment of mental vigor. The emotions are easily excited, 
and the temper becomes fretful and irritable. Hallucinations are not 
uncommon, and these are generally connected either with the sight or 
hearing. Sometimes both these senses are involved. 

The sleep is generally disturbed by disagreeable dreams, sometimes 
reaching to the intensity of nightmare, and these are so vivid that the 
patient often considers them realities. 

In a few cases there is decided mania, but this is. not of a very 
aggravated form, and is of temporary duration. Three such instances 



CHOREA. 711 

have recently been under my care, all occurring in young girls of about 
the age of puberty, and exhibiting in all other respects the typical 
characteristics of chorea. 

In two cases under my observation, the first notable event in the 
course of the disease was an epileptic paroxysm, which, however, was 
not repeated in either case. 

The most prominent symptoms of the disease are, in the great ma- 
jority of cases, exhibited in the irregular and disorderly muscular con- 
tractions which make their appearance at a very early period, and 
which have given it a name in nearly every language of the civilized 
world. Thus, we have the terms chorea (#opeta, a dance), St. Vitus's 
dance, St. Gay's dance, etc. 

In the beginning the foot of one side drags a little, and soon after- 
ward the corresponding upper extremity becomes affected with the 
choreic movements. These are manifested in the fingers, in the flexion, 
extension, and rotation of the wrist, and in the movements of the elbow 
and shoulder. No matter where the hand be placed, it cannot be kept 
steady, but it and the whole extremity are in a constant state of agita- 
tion. Before long the muscles of the neck and face participate, the 
head is jerked from side to side, and a continual series of grimaces is 
the result of the actions in the facial muscles. 

In some' cases the involuntary movements are confined to one lat- 
eral half of the body, constituting the form known as hemichorea. 
This is the case in about one-fourth of the instances. Thus, of two hun- 
dred and thirty-five cases cited by See, 1 the phenomena in sixty-four 
were limited to one side. This limitation has not, as was formerly 
supposed, any relation with hemiplegia, but is solely the result of the 
suspension of the progress of the disease. 

At first the movements are moderate, but they go on, becoming 
more and more severe, until, in extreme cases, the condition of the pa- 
tient becomes exceedingly pitiable. The arms, the legs, the face, and 
head, are in almost constant action. Every attempt to perform a vol- 
untary movement excites still more the disorderly actions, and thus the 
patient is unable to feed or dress himself, and sometimes even walking 
becomes impossible. 

In one type of cases the convulsive movements come on paroxys- 
mally, and are often of the most astonishing character. The patient is, 
perhaps, lying quietly on the bed, when suddenly the head is thrown 
backward, the limbs set in involuntary motion, and the muscles of the 
trunk contract so violently as to throw the sufferer forcibly to the floor. 
Again, a series of gyratory motions ensues, and the patient turns 
round on one foot until complete exhaustion follows ; or there may be 

1 " De la choree et des affections nerveuses en general, avec leurs rapports avec les 
diatheses, et principalement avec le rheumatisme,'' " Mem. de l'aeademie de medecine," 
1850, tome xiv., p. 343, et seq. 



712 CEREBRO-SPINAL DISEASES. 

leaps and contortions of various kinds. Sometimes the movements are 
rhythmical. A lady, who was under my charge, was suddenly seized 
with an irresistible impulse to bend the left elbow. The arm con- 
tinued in motion for half an hour, and then the right arm began a like 
movement. In a few minutes the head began to nod, then the left 
knee was alternately flexed and extended, and finally the right knee 
became similarly affected. For over an hour these movements con- 
tinued, and then a regular alternation ensued — first the left arm, then 
the right, then the head, next the left leg, and finally the right leg. 
These actions were perfectly timed, and were all performed in exactly 
ten seconds, as I ascertained by determinations made on several occa- 
sions. As she sat in a chair, or lay on a bed, she was a curious sight. 
Though she was good-tempered with it all, her emotional system was 
in a state of great exaltation. She recovered in a few weeks. 

Chorea of rhythmical or uniform character has often prevailed epi- 
demically. The most authentic recorded visitation of the kind was one 
which occurred at Aix-la-Chapelle in 1374. This was in the form of a 
dancing mania, and is fully described by Hecker * under the name of St. 
John's dance. The men and women subject to it met in the streets 
and churches, where " they formed circles hand-in-hand, and, appearing 
to have lost all control over their senses, continued dancing, regardless 
of the by-standers, for hours together in wild delirium, until at length 
they fell to the ground in a state of exhaustion. They then complained 
of extreme oppression, and groaned as if in the agonies of death, until 
they were swathed in cloths bound tightly around their waists, upon 
which they again recovered, and remained free from complaint until the 
next attack. This practice of swathing was resorted to on account of 
the tympany which followed these spasmodic ravings, but the by- 
standers frequently relieved patients in a less artificial manner, by 
thumping and trampling upon the parts affected. While dancing they 
neither saw nor heard, being insensible to external impressions through 
the senses, but were haunted by visions — their fancies conjuring up 
spirits, whose names they shrieked out ; and some of them afterward 
asserted that they felt as if they had been immersed in a stream of 
blood, which obliged them to leap so high. Others, during the parox- 
ysm, saw the heavens open and the Saviour enthroned with the Virgin 
Mary, according as the religious notions of the age were strangely and 
variously reflected in their imaginations. 

In the most fully-developed and best-marked instances of the dis- 
ease, it was often ushered in by an attack of epileptic convulsions. 
Such were probably cases of hystero-epilepsy, an affection to be pres- 
ently considered at greater length. 

The affection spread like wild-fire — being fed by that principle of 
imitation which appears to be so powerful an influence in causing the 

1 " Epidemics of the Middle Ages," " Sydenham Society Translation," 1844, p. 87. 



CHOREA. 713 

propagation of this and analogous disorders of the nervous system. 
Those affected were generally regarded as being possessed by evil de- 
mons, and consequently only to be cured by the exorcisms of the clergy. 

In 1418 it broke out in Strasbourg, and there received the name of 
St. Vitus's dance, from the fact that the most efficacious means of cure 
was thought to consist in the intercession of this saint. 

Similar attacks of dancing mania had occurred before that of St. 
John, but the details are more or less obscure, and several have occurred 
since. Among these latter must be placed the tarentism which overran 
Italy, and various more restricted epidemics of like disorders. In our 
own country we have had the Jumpers, and we still have the Shakers. 
In addition to these are many of the manifestations of witchcraft, which 
were choreic, and of which this country has had its full share, and of 
spiritualism, which it enjoys the doubtful honor of having initiated. 1 

Huntington has described a form of chorea which occurs in families, 
and seems to be influenced by heredity. Several instances of the dis- 
ease occurring in one family have come under my observation. It differs 
materially from ordinary chorea in that it does not make its appear- 
ance until adult life, that there is every evidence of mental deteriora- 
tion, and that the disease is progressive, and usually terminates fatally. 

In chorea, even of the ordinary simple kind, the speech is imperfect, 
owing to the incoordination of the muscles directly concerned in articu- 
lation, and those which affect respiration. There are, therefore, stutter- 
ing and stammering, and at times a peculiar difficulty of speaking, ow- 
ing to the attempt being made when the chest is empty ; that is, when 
expiration has just been accomplished. The vocal cords are sometimes 
affected, causing the individual to utter peculiar sounds, such as bark- 
ing, grunting, and sighing, both on inspiration and on expiration. The 
tongue and lips rarely escape being involved to a considerable extent. 

The muscles of mastication and deglutition are generally affected, 
and hence the food is imperfectly chewed, and often causes choking 
from difficulty of swallowing it. 

In some cases chorea is accompanied with paralysis — the chorea 
paralytica of authors. This loss of the power of voluntary motion is 
usually hemiplegic, and involves the same muscles, which are the seat 
of the irregular movements. Occasionally there are contractions of 
the limbs, but not to any great degree. 

Dr. Weir Mitchell 2 has also called attention to disorderly move- 
ments supervening after paralysis, to which he applies the term of 
post-paralytic chorea. The propositions which he enunciates are : 

1. That adults who have had hemiplegia, and who have entirely 
recovered, are often the subjects of choreal disorder. 

1 See the author's " On Certain Causes of Nervous Derangement," for more complete 
details on this and analogous subjects, and for accounts of other examples. 

2 "Post-Paralytic Chorea," American Journal of the Medical Sciences, October, 1874. 



714 CEREBRO-SPINAL DISEASES. 

2. That the younger the patient the more apt these choreal devel- 
opments are to ensue. 

Dr. Mitchell adduces several interesting cases in support of these 
propositions, and quite a large number have come under my own obser- 
vation. But the condition in question is an entirely different affection 
from athetosis, with which it has been frequently confounded. 

Chorea is sometimes of very limited extent. It may be only shown 
in the hand or foot, but more frequently, when restricted in its topog- 
raphy, it is manifested in the head or face. There may be only a little 
twitching of the muscles at the angles of the mouth, or of those which 
raise the upper lip, or of the orbicularis palpebrarum, by which the 
eyelids are closed, or of the levator palpebrse superioris, or of the 
corrugator supercilii, or occipito-frontalis. Sometimes the head is ro- 
tated suddenly, or twitched to one side, or there is a shrugging of the 
shoulders. 

In several cases that have been under my care, the abnormal mani- 
festations were entirely confined to the organs of voice or speech. In 
one instance — that of a young girl from Illinois — while there was a 
general hyperesthesia of the whole nervous system, there were no 
choreic movements except of the respiratory and laryngeal muscles. 
The respiration was therefore exceedingly irregular, and at times inar- 
ticulate sounds were made, which were involuntary. Articulate speech 
was lost from inability to coordinate the muscles, but there was no 
paralysis, for the tongue could be moved freely in all directions, and 
the lips were as mobile as ever, except when the patient made an effort 
to speak. After a few weeks the sound from the larynx was made 
regularly at each expiration. There were no sounds during sleep. 

In this case there was a strong hysterical element present. The 
affection resisted all treatment, and finally I sent the patient home, 
scarcely improved except in her general health. One morning she 
awoke, began to speak, and there was no resumption of the laryngeal 
sounds. She has continued well ever since, now over two years. 

Again, there may be an irregular action of the muscles of speech, 
and in consequence words are uttered against the will of the patient, 
and often without any previous knowledge of what is going to be said. 
The language used is often of a profane or indecent character. 
This condition has been termed "coprolalia." Several such cases have 
been under my observation, and I have alluded to two of them in a recent 
lecture 1 on chorea. Since then another remarkable case of the kind 
has come under my care. In this instance there is scarcely a minute 
during the day that the speech is not going on, and this without the least 
power on the part of the patient to arrest or direct it. If he is asked a 
question, he can only use a few apposite words, the others being alto- 
gether without relation to the subject about which he wishes to speak. 
1 Journal of Psychological Medicine, January, 1871, p. 51. 



CHOREA. 715 

The convulsive movements in chorea almost invariably stop during 
sleep. They are also sometimes temporarily arrested by intense men- 
tal occupation, but are always rendered worse by emotional disturbance 
or physical fatigue. On the contrary, they are diminished by mental 
and emotional quietude. 

Strange as it may appear, the sensation of being tired is scarcely 
ever experienced by choreic patients. Generally there are wandering 
pains in the limbs, headache, and pain in the back. The cutaneous 
sensibility is usually increased, but in some cases it is greatly lessened, 
and may be abolished altogether in some parts of the body. 

The functions of the several viscera are ordinarily more or less de- 
ranged. There are paroxysms of palpitation of the heart, and the 
action of this organ is to some extent irregular during the whole course 
of the disease. Endocardial murmurs are often present, either systolic 
or diastolic, but are the result of the anaemia which is so prominent a 
feature of chorea. Respiration is imperfect ; the stomach does not 
digest well ; and there are nausea and vomiting. The bowels are con- 
stipated ; the urine is loaded with phosphates, and is of diminished 
quantity ; and the menstrual function in girls is imperfectly performed, 
either as regards quantity or quality. The skin is dry and harsh, the 
hair loses its gloss, the complexion is pale, the lips bloodless, the 
pupils dilated, and the sclerotic coat of the eye of more than normal 
whiteness. 

The tendency of chorea is to increase to a certain point, and then 
to gradually diminish. In favorable cases occurring in children, it runs 
its course in about three months. This period can be materially short- 
ened by appropriate treatment. Sometimes it ceases very suddenly, 
and in others passes into a chronic condition, which may last for years 
or during the life of the patient. Occasionally it terminates in death, 
either directly or in consequence of the supervention of some inter- 
current affection. Three fatal cases have come under my observation. 
One of these I saw several times in consultation with my friend Dr. T. 
G. Thomas. The patient was a young lady about twenty years of age, 
and her paroxysms were of the most violent character, sometimes being 
so strong as to cause her to throw herself off the bed, or to dash about 
the room with great force. No treatment appeared to exercise any re- 
straining effect, and, after about two years, she died of an abdominal 
affection. There was no post-mortem examination. In the other two 
cases, death ensued from exhaustion. 

Relapses are common in chorea, especially in children, and some- 
times as many as half a dozen attacks occur. Subsequent seizures are 
usually less severe than the first. 

Chorea is often complicated with hysteria — a combination which 
will be described hereafter. It may also exist in conjunction with 
rheumatism and malarial fevers, and the exanthemata. 



716 CEREBRO-SPINAL DISEASES. 

In an interesting monograph, Dr. Gowers ' gives the results of his 
studies and investigations relative to certain features of the choreic 
condition. He found that the electric excitability of both nerves and 
muscles on the affected side in cases of hemichorea is increased in most 
cases after the lapse of a few weeks ; that there is no necessary rela- 
tion between the spontaneous spasmodic movements of the affected 
muscles and the incoordination which takes place when voluntary 
movements are attempted ; that there is no regularity about the dis- 
tribution of the disorderly movements in cases of hemichorea, and that 
there appears to be a relation in some cases of chorea with other con- 
vulsive affections, such as hysterical and epileptoid seizures of various 
kinds, and even true epilepsy. As Dr. Gowers observes, this relation, 
the existence of which is unquestionable, points in some cases to a com- 
mon origin ; in others, to a predisposition excited by the one disease. 

Causes. — Chief among the predisposing causes of chorea is age. It 
is more frequent during the period extending from six to fifteen years 
than during all the rest of life. See, of five hundred and thirty-one 
cases, found four hundred and fifty-three of ages ranging from six to 
fifteen years. 

During the last ten years, in my hospital and private practice and 
at my clinics, many cases of chorea have come under my observation 
and treatment, but I have kept no systematic account of them since 
the first edition of this work was published (1871). At that time I 
had full notes of eighty-two cases ; of these, sixty-seven were of ages 
between six and fifteen years. Under the age of six, the disease is less 
frequent as we go toward birth. Cases have been met with in infants 
at the breast of six months old. The youngest case I have had was a 
girl of eighteen months. 

After fifteen, the disease, unless it occurs as an epidemic, is not 
very common. Cases are, however, met with in adults, and even in 
very old persons. I have seen four cases in individuals over thirty, and 
three in persons between the ages of twenty and thirty. Of course, I 
refer to the origination of the disease at these ages : instances of its 
beginning in childhood, becoming chronic, and lasting through life, are 
not so rare. In those cases reported by authors of the affection origi- 
nating very late in life, we have every reason to conclude that they 
were instances of organic lesions of the brain or spinal cord — probably 
sclerosis — giving rise to rhythmical movements or paralytic tremor. 

The female sex is much more liable to chorea than the male. Of 
See's five hundred and thirty-one cases, three hundred and ninety-three 
were girls and one hundred and thirty-eight boys. 

Of the eighty-two cases of which I have full records, seventy were 
females and twelve males. Rheumatism has been supposed to be a 

1 " On some Points in the Clinical History of Chorea." Reprinted from the British 
Medical Journal, London, 1878. 



CHOREA. 717 

predisposing cause of chorea. Of one hundred and twenty-eight cases, 
See found sixty-one in association with rheumatism ; but when we come 
to inquire further, we find that only thirty-two of these were articular 
rheumatism, while the rest were cases in which there were wandering 
pains which may have been, and probably were, without the least affin- 
ity with true rheumatism. 

While it is certainly the case that chorea sometimes follows or 
exists coincidentally with rheumatism, I doubt if its influence is any 
more than that of a depressing agent to the organism. Of the eighty- 
two cases observed by myself, only sixteen were connected with rheu- 
matism, while eighteen were just as intimately related to other dis- 
eases. 

The affection appears to be more common in winter than in sum- 
mer. Of my cases, fifty-four occurred in the six months from October 
to March, and twenty-eight in the other six months of the year. 

Among the exciting causes, those connected with the emotions 
occupy the first place. Twenty-seven of my cases were directly the 
result of fright, apprehension, anxiety, mental excitement, or some 
other cause of the kind. In eight it was induced by intense study at 
school, and in four from imitating others similarly affected. This lat- 
ter factor is not of so general application as in former times, when 
social life was different. To it is, doubtless, to be ascribed the spread 
of choreiform movements through certain localities, and especially 
convents, such as occurred in the thirteenth, fourteenth, and fifteenth 
centuries, to some of which reference has already been made. 

Recently the theory has been advanced that eye-strain is a frequent 
cause of chorea. It is possible that such a condition in a few instances 
may be a contributing cause in a person predisposed to chorea, but in 
the main I am inclined to consider such influence as exceedingly slight. 

Among other causes, bad hygienic influences and exhausting dis- 
eases generally are to be mentioned. 

Pregnancy is also asserted to be a cause, and cases are on record in 
which the foetus has been born choreic of a choreic mother. 

Diagnosis. — There is not much danger at the present day that 
chorea will be confounded with many of the diseases from which, not 
long ago, it was not clearly disassociated. Thus, from paralysis agitans, 
epilepsy, locomotor ataxia, multiple cerebral and cerebro-spinal scle- 
rosis, the fuller acquaintance which we have in recent years acquired 
of these maladies prevents the necessity of dwelling on their character- 
istics as distinguished from those of chorea. The course of the latter 
disease, and the symptoms, other than those connected with motility, 
are in the others so different that no one who has studied their phe- 
nomena could fail in making a correct diagnosis. 

With hysteria, some of the forms of chorea may be confounded, 
and the two affections are not infrequently blended in the same person. 



718 CEREBRO-SPINAL DISEASES. 

It must be confessed, too, that there are cases in which the diagnosis 
cannot be clearly made out. So far as the patient is concerned, the 
difficulty of forming a correct opinion in such cases is not a matter of 
much moment. 

The great majority of cases of chorea, such as are met with in chil- 
dren, are readily distinguished from hysteria. The facts of the disease 
occurring before puberty in so large a proportion of instances, that the 
emotional system is rarely disturbed as in hysteria, that the affection is 
not so paroxysmal, and that the accessions of hysteria are more sud- 
den, will be sufficient to render the diagnosis accurate. 

From convulsive tremor — with which in some of its forms it is 
closely analogous — ordinary chorea is diagnosticated by the facts that 
it is not paroxysmal, but continues while the patient is awake, that the 
movements are more disorderly, while at the same time more purposive, 
that the natural tendency is toward spontaneous recovery and that it 
usually occurs in children. But it must be admitted that it is difficult 
to determine to which disease certain rhythmical and paroxysmal dis- 
orders are to be ascribed. It would perhaps be more correct to place 
all such under the head of convulsive tremor or hysteria, with which 
affections they are certainly closely allied. 

Prognosis. — This is usually favorable in those cases which occur 
before puberty. The chorea of adults is, however, in most instances, a 
very unmanageable affection, and generally either terminates in death 
or becomes permanent. Cases in which death has ensued have been 
reported by various authors — among them, Dr. John W. Ogle, 1 Dr. J. 
Hughlings Jackson, 2 and Dr. G. See. 3 As already stated, three fatal 
cases have occurred in my own experience. The tendency, however, 
in the chorea of young persons is decidedly toward recovery, even 
under unfavorable circumstances as regards hygiene or medical treat- 
ment. 

Morbid Anatomy and Pathology. — In many cases of persons dying, 

either from chorea or from intercurrent affection, no changes have been 
found which could, with probability, be regarded as constituting the 
disease. In other cases, morbid alterations from the healthy state have 
been found. The idea has therefore prevailed that there are two 
kinds of chorea — one which is entirely functional, belonging to the so- 
called neuroses, the other the result of organic disease of the brain or 
spinal cord, or both. In Ogle's sixteen fatal cases, congestion of the 
brain and its membranes was found in some, while in others the dis- 
ease existed in the spinal cord. 

1 " Remarks on Chorea Sancti Yiti, including the History, Course, and Termination 
of Sixteen Fatal Cases," etc., British and Foreign Medico- Chirurgical Review, January, 
1868, p. 208. 

2 " The Physiology and Pathology of Hemi-Chorea," Edinburgh Medical Journal, Oc- 
tober, 1868. 

3 Op. cit. 



CHOREA. 719 

In an analysis of one hundred cases of chorea, Dr. Hughes * cites 
fourteen fatal cases. In all but four of these there was intra-crauial 
congestion with other structural changes, such as softening, opacities, 
and adhesions. The spinal cord was not examined in six cases. Of 
the remaining eight, it was healthy in three, and congested, softened, 
or with adhesions or opacities of the membranes in the remaining five. 

In seven fatal cases, collected by Romberg, 2 there was softening 
and degeneration of different parts of the brain and of the spinal cord. 

Other similar cases have been reported, and in the majority there 
were fibrinous concretions on some portion of the heart's valves or 
lining membrane. 

In 1850 and 1863, Dr. Senhouse Kirkes 3 published the details of a 
number of cases which went to show the association between chorea 
and rheumatism, and he made the prediction that "future experience 
will still more positively demonstrate that an affection of the left valves 
of the heart, with the presence of granular degeneration upon them, is 
an almost invariable attendant upon chorea, under whatever circum- 
stances the chorea may be developed." The relation is also insisted 
upon by See and other authors, and such cases as those of Ogle are 
cited in its support. But the doctrine is only applicable, with any 
probability, to the fatal cases, and, in those of Ogle, rheumatism was 
not always an antecedent. In regard to this point, I am entirely in 
accord with the views expressed by Dr. Ogle in the following extract, 
which I make from his valuable paper : 

" Again it might be asked, if there was merely a mechanical cause 
(which, of course, would be constant in operation), such as embolism, 
why should the movements be so decidedly and universally interrupted 
during quiet sleep ? Or, why should certain peculiarities as to age or 
sex be considered as predisposing influences ? Recognizing the fre- 
quent existence of these fibrinous deposits, or granulations, on the 
heart's valves in chorea, I should be much inclined to look upon these 
post-mortem appearances rather as results of some antecedent condition 
of the blood, common also to the choreic condition. It is very freely 
recognized that this affection is frequently in some way or other con- 
nected with that condition of blood which obtains in what we call 
anaemia, or that existing in rheumatic constitutions. In both of these 
states we know that the fibrine of the blood is much m excess (as also 
it is in pregnancy and other conditions looked upon as obnoxious to 
chorea), and in these states we know that the fibrine (with which the 
blood is surcharged) is very prone to be readily precipitated, either 
owing to its superabundance or from other obscure and acquired prop- 

1 "Digest of One Hundred Cases of Chorea," "Guy's Hospital Reports," vol. iv., 18^6, 
p. 360. 
• ' 2 " Lehrbuch der Nervenkrankheiten," Band ii. 
3 London Medical Gazette, 1850, and Medical Times and Gazette, 1863. 



720 CEREBRO-SPINAL DISEASES. 

erties (possibly also from some interference with the relation of the 
fibrine and the other constituents of the blood), upon the heart's walls 
or valves. May not this hyperinosis be the explanation of the coinci- 
dence alluded to ? In most cases, the deposit is probably very slight, 
and, in many cases, so slight as to require search for it. May it not 
infrequently be that it is often only found in quite the dying state ? 
Speculation might suggest that the fibrinous deposits arise from some 
interference with the degree of solubility of the fibrine, induced by 
the presence of some ununited elements within the blood (some result 
of tissue-metamorphosis) produced by the excessive muscular action 
and other functional disturbance which exist in the choreic state, thus 
being not in any way related to this state as a cause, but as a conse- 
quence." 

In the paper to which reference has already been made, Dr. Hugh- 
lings Jackson associates hemichorea with the plugging by emboli of 
the vessels of the corpus striatum of one side, and, in a recent valuable 
paper, Dr. Charlton Bastian 1 says : 

" I need only hint at the important bearing which the possibility of 
the occurrence of minute embolisms of this kind may have in the eluci- 
dation of previously-obscure forms of so-called functional disease of the 
nervous system, as I hope shortly to publish the details of a fatal case 
of chorea, in which such embolisms led to ruptures and obliterations 
of small vessels throughout the corpora striata and in the course of the 
middle cerebral arteries generally — this being a case of bilateral chorea 
in which delirium was also present." 

As the result of our present knowledge of the morbid anatomy of 
chorea, while it cannot be said that we are always able to define its 
seat with accuracy, we have strong evidence to support the view that 
it is caused by either functional or by organic irritation of motor cells 
in the cerebro-spinal system. In this respect it differs but little, if 
any, from the morbid anatomy of the other forms of mobile spasm. 
Irritation of the motor cells of the cortex, the corpus striatum, the 
pons, and probably the spinal cord, is responsible, in my opinion, for 
the manifestations of chorea. As previously stated, I am inclined to 
think that there are at least two distinct diseases — one due to spinal 
and the other to cerebral lesion, the latter probably consisting of sev- 
eral forms — but that it is advisable to consider them as one disease of 
various types, until further investigation enables us to speak with cer- 
tainty on the subject, and to classify them according to the morbid 
anatomical condition of each. 

The investigations of Chauveau, 2 Le Gros and Onimus, 3 and others, 
upon choreaic dogs : the lesions discovered in the spinal cord in fatal 

1 " On the Plugging of Minute Vessels in the Gray Matter of the Brain," etc., British 
Medical Journal, January 30, 1869, p. 96. 

2 Archiv. generales de ?jied., 1865. 3 Cornptes rendus, 1870. 



CHOREA. 721 

cases of chorea by Hughes, 1 Romberg, 2 Ellischer, 3 and Bastian ; 4 and 
cases such as those reported by "Weir Mitchell and Burr, 5 show the 
probability, at least, of the spinal cord being the seat of the primary 
morbid changes in some instances. 

In the paper already cited, Dr, Hughlings Jackson says of the cho- 
reic phenomena : " They are not mere spasms and cramps, but an aim- 
less progression of movements of considerable complexity, much nearer 
the purposive movements of health. They are not so much incoher- 
ences of muscles (like the ' fist ' we see in a partial fit of those convul- 
sions, which begin unilaterally where all the muscles of the hand are 
in action at once) as incoherences of movements of muscles. There is 
some method in their madness. They are not analogous to playing at 
once many keys of a piano in mere order of continuity, but to a 
random playing of harmonious chords. Again, they are successions 
of movements ; moreover, they are successions of different move- 
ments." 

Dr. Jackson's theory of chorea is, that it is, like epilepsy, the result 
of " discharging lesions " of the cortical matter of the cerebrum ; and 
the experiments of Fritsch and Hitzig, Nothnagel, Ferrier, and others, 
go very far to confirm his views. Two essential points of difference 
from epilepsy must, however, be noted : the facts that in chorea there 
is no loss of consciousness, and that the discharges are successive, not 
paroxysmal, and less automatic. Moreover, his hypothesis leaves out 
of consideration the spinal element of the disease. That there are dis- 
charging and inhibitory centres in the spinal cord is supported by many 
artificial and natural experiments. The " spinal epilepsy " of Brown- 
Sequard is doubtless often a chorea of spinal origin ; and my own 
experiments, cited under the head of convulsive tremor, also show that 
there are motorial centres in the spinal cord. 

Treatment. — Diseases which are almost certain to terminate fatally, 
and those which ordinarily recover without medical treatment, are 
very sure to have a great many medicines used in their therapeutics. 
Chorea belonging, as it doe£, to this latter category, has a medical 
armamentarium almost equaling that of hydrophobia. I shall, of 
course, not even pretend to mention all these measures, but will, 
merely cite those which the weight of evidence, and especially that 
derived from my own experience, indicates as the most effectual. Of 
the benefit to be derived from proper medical treatment in shortening 
the duration of the disease, and preventing chronicity, I have no doubt. 

Bromide, in some one of its forms, is a favorite remedy for chorea. 
I have employed it in many cases, and sometimes with good results. 
My preference is for the bromide of sodium, in doses of from ten to 
fifteen grains, three times a day, dissolved in a sufficient quantity of 

1 Op. cit. 2 Op. cit. 3 Arcliiv fur path. Anat. } Berlin, 1874. 

4 Op. cit. 5 "Trans. Amer. Neurol. Assoc.," 1890. 

47 



722 CEREBRO-SPINAL DISEASES. 

water to prevent gastric irritation. In the majority of instances, how- 
ever, I am opposed to its use. While admitting that the preparations 
of bromide diminish nerve-cell irritability, it is also well established 
that they depress the system, weaken the muscular power, and, by con- 
tracting the arterioles, prevent the proper nutrition of the brain and 
spinal cord. I have therefore confined their administration to those 
cases in which the chorea coexists with maniacal symptoms, insomnia, 
or other symptoms of a hypersemic condition of the brain. 

Iron is also frequently administered as a sole remedy, and still more 
generally as an adjuvant. Indeed, no matter what special treatment 
may be adopted, iron is generally indicated to improve the quality of 
the blood. I rarely use it unless for this latter purpose. 

Tartarized antimony, copper, sulphate of aniline, Calabar bean, and 
various other substances have been employed with more or less suc- 
cess, according to reports, but I have little personal experience of their 
value, except as regards the Calabar bean, which I have several times 
employed as an adjuvant, but with doubtful results. 

I have used both the primary galvanic and induced currents in 
many cases. In my opinion they are inefficacious except in that form 
in which there is distinct paralysis. 

Arsenic enjoys a high reputation in the treatment of chorea, and, 
if properly administered, may be regarded as almost a specific. It 
should be given in gradually-increasing doses up to the point of induc- 
ing evidence of its toxic influence, such as nausea and vomiting and 
puffiness of the face, especially under the eyes. For a child of five or 
six years the initial doses may be four drops of Fowler's solution three 
times a day for the first day ; for the next day, five drops are given 
at a dose ; for the next, six, and so on till the phenomena mentioned 
appear. Then the doses should be set back to four or five drops, and 
again increased as before. Of the benefits of this treatment no one 
who has tried it can have any doubt. Its advantages have been shown 
in a report of cases from the clinique of the University Medical Col- 
lege, made by Dr. Morton. 1 But the gastric method of administering 
arsenic is not so efficacious in the treatment of chorea as the hypoder- 
mic, and in a recent paper 2 I called attention to this point, following 
Radcliffe, who over ten years ago introduced the practice : 

In this country hypodermic injections of arsenic in the treatment 
of chorea appear to have been first used by Dr. J. Lewis Smith, 3 but 
since that time the measure does not seem to have attracted any at- 
tention. 

For the last ten years I have, in obstinate cases of chorea, em- 

1 "Treatment of Chorea by Arsenic," Neurological Contributions, No. II., p. 79. 

2 " On the Treatment of Chorea with Hypodermic Injections of Arsenic," St. Louis 
Clinical Record, October, 1879. 

8 Medical Record. 



CHOREA. 723 

ployed hypodermic injections of Fowler's solution with, marked suc- 
cess. In recent or slight cases they do not appear to be necessary, 
these yielding readily to the use of arsenic by the stomach, or very 
often getting well of themselves ; but in instances of long standing, 
which are generally classed as incurable, I am quite sure that we 
have, in the means referred to, a valuable therapeutic measure, which 
ought not to be disregarded. 

In administering arsenic by this method a few points of manipula- 
tion are to be considered, for there is a decided tendency to the causa- 
tion of cellulitis and consequent abscess, and also of painful cutaneous 
inflammation. 

A point for the injection should be chosen in some part of the 
body where the skin is loosely attached to the subjacent tissues. The 
skin near the insertion of the deltoid is not a suitable place for the 
hypodermic injection of arsenic, however well adapted for injections 
of other substances. I very soon found out that, when inserted there, 
erythema or abscess, or both, were the invariable sequences. More- 
over, the mere act of injecting arsenic in those situations where the 
skin is tight and the tissues dense is accompanied with very consider- 
able pain. 

The best point is on the front of the forearm about midway between 
the wrist and the bend of the elbow. Here the skin is loose, and can 
be easily lifted up by the thumb and finger from the tissues below. 
In the next place the arsenic should be deposited just under the skin 
in the cellular tissues, and not in the substance of the skin or muscles. 
Neglect of this point will almost invariably lead to the formation of 
abscess. The point of the syringe should therefore be just carried 
through the skin and then for about half an inch parallel to the face 
of the arm. The injection should then be made slowly, and it is well 
to lift up the skin over the place where the injection has been made, 
so as further to facilitate its absorption. 

And, lastly, it will not do to inject the undiluted Fowler's solution, 
for if this provision be not followed, cellulitis, erythema, and intense 
pain, will certainly be produced. The dose which it is deemed proper 
to inject should be diluted with at least an equal quantity of water, 
or, preferably, of glycerine. The latter substance seems to be more 
readily absorbed and to produce less irritation than water. All these 
precautions are for the purpose of preventing local troubles. There is 
certainly a strong disposition on the part of arsenic to produce them. 
If, however, attention be paid to the rules I have laid down, there 
will rarely, if ever, be any local disturbance. 

The dose of arsenic administered by hypodermic injection may be 
very considerably larger than that which the stomach will ordinarily 
tolerate, and it is just here that the superior advantages of the method 
are most clearly shown. It is in chronic cases of chorea and certain 



724 CEREBRO-SPINAL DISEASES. 

choreiform affections that large doses of arsenic are especially re- 
quired, and the effect of such doses in curing the disease is not only 
generally prompt, but is unassociated with any toxic phenomena. I 
have frequently given as high as thirty-five drops of Fowler's solution 
by hypodermic injection as an initial dose. It is very certain that the 
stomach would not tolerate this quantity. Again, I have often car- 
ried the amount taken by the stomach to the utmost bounds of pru- 
dence — till the eyes were puffed, and vomiting was almost incessant — 
and then have continued the arsenic in larger doses by hypodermic 
injection, with the result of the cessation of all gastric symptoms and 
the rapid cure of the disorder. 

With these introductory remarks I pass to the description of two 
or three cases in which the beneficial effects of the arsenic adminis- 
tered hypodermically were unquestionable : 

Case I. — Mrs. A. C, of Jersey City, consulted me, not for chorea, 
but for a spasmodic affection of the muscles of the neck attended 
with great pain. On examination, I found that the left sternocleido- 
mastoid was the subject of clonic spasm, and that the left trapezius 
was also similarly involved. As a consequence the head was, every 
few seconds, jerked round toward the right shoulder, at the same time 
being drawn backward. It was possible, by a strong effort of the 
will, to arrest these movements for a half a minute, and at times, when 
alone and undisturbed, they were less strong and frequent. During 
sleep they entirely ceased. The affection had come on suddenly some 
five years previously, apparently as the result of exposure to cold. 
"No therapeutic measures (among which had been electricity, water- 
cure, and braces of various kinds) had produced the slightest bene- 
ficial effect. 

In the beginning I administered Fowler's solution in doses of eight 
drops three times a day, increasing the doses a drop every day. When 
sixteen drops were reached, the skin around the eyes became puffed, 
and each dose excited nausea and vomiting. Up to this time there 
had been a very slight degree of improvement, but I found it was im- 
possible to carry the arsenic far enough when administered by the 
stomach to get the full effect of the drug. I therefore, on the 20th, 
administered hypodermically one injection of twenty-five drops diluted 
with a like quantity of glycerine. On the 21st she received thirty 
drops, and now there were decided evidences of improvement — the 
pain was greatly mitigated, and the spasmodic movements were less 
extensive and less frequent. On the 21st thirty -two drops were given, 
and on the 22d thirty-five. The amelioration was now still more 
strongly marked, and by continuing the doses of thirty-five drops till 
the 25th the pain and the movements were caused to cease entirely. 
The medicine was now stopped, and the patient has remained to this 
day free from any spasm. There is still (October 6th) a slight ten- 



CHOREA. 725 

dency for the head to turn to the right, but this is being gradually- 
overcome, and the power over the formerly affected muscles is com- 
plete. 

Case II. — Miss H., aged twelve, a young lady from Texas, was 
brought to me by her mother to be treated for chorea, with which she 
had been affected for several months. The muscles chiefly affected 
were those of the face, both shoulders, and both upper extremities, but 
at times there was a curious protrusion of the abdomen from the spas- 
modic action of the erector spinas muscle. 

I at once began the treatment with arsenic and the application of 
pulverized ether to the spine, the former in doses of five drops of 
Fowler's solution three times a day, increased a drop every alternate 
day, and the latter once daily. By the time ten drops of the arsenical 
solution was reached (which was in ten days), there was decided im- 
provement. The eyes were slightly puffed, but the stomach bore the 
remedy exceedingly well. I continued the medicine up to fourteen 
drops without exciting gastric disturbance, and then, as the choreic 
movements had ceased, I refrained from further increase, but kept on 
with the doses of fourteen drops for three or four days longer. She 
then went home cured. 

But in six months she returned to me, with all the choreic symp- 
toms as bad as ever, and her mother informed me they had made their 
appearance a couple of weeks before without apparent cause. I again 
tried the arsenical treatment with ether to the spine, which had been 
so beneficial the year before, but it was now apparent that, from some 
cause or other, the stomach had become intolerant of the drug, for I 
found it impossible to administer with safety more than eight drops, 
and this quantity had no beneficial influence over the disease. I there- 
fore determined to use the hypodermic injections. Twelve drops were 
the initial dose, the next day thirteen were given, the next fourteen, 
and the next fifteen. There were no choreic movements after this dose 
was attained. It was given daily for a week, and then the patient was 
discharged cured. In all this time there had been no toxic symptoms 
beyond slight puffing of the face. 

Case III. — I. H., a boy eight years of age, was brought to me 
affected with general chorea. The case was a chronic one, having 
lasted about a year, and had been treated by his physician with a 
single drop of Fowler's solution administered once every alternate 
day, and with sulphate of zinc in about as efficacious doses. I be- 
gan the treatment in this case with h}'podermic injections of five 
drops of Fowler's solution given daily, and every alternate day in- 
creased a drop. In ten days thereafter the patient was taking "ten 
drops daily. As by this time great amelioration had ensued, I did not 
carry the increase further, but, with the.view of preventing a relapse, 
the doses were continued for several days. On the 28th all treat- 



726 CEREBROSPINAL DISEASES. 

ment was suspended, the patient being entirely free from choreiform 
movements. 

In cases of acute chorea, a large number of which I have treated 
with hypodermic injections of arsenic, smaller doses may be given than 
when administered by the stomach, and they do not require to be so 
frequently repeated. Thus it often suffices, for the speedy cure of the 
disease, to give four drops of Fowler's solution hypodermically every 
alternate day for a week or ten days, and then to increase the dose to 
five drops for a like period. I have compared the duration of acute 
chorea as treated by the gastric and hypodermic administration of 
arsenic, and have ascertained that the period is shortened one half by 
the latter method. While admitting that the tendency in such cases 
is, with hygienic measures, toward a cure, the beneficial effects of the 
arsenic are none the less evident. I have repeatedly seen the most 
marked improvement result from a single injection. 

In his excellent monograph Garin ' has insisted on the advantages 
of this method of treating chorea, and has adduced many instances of 
its good effects. 

As to the employment of strychnia, as detailed in former editions 
of this work, I am not disposed to recommend it, in view of the excel- 
lent results obtainable by the use of arsenic, except in special cases, in 
which, from some idiosyncrasy, the latter medium is not tolerated. 
It may also be of service as an adjunct in moderate doses. 

The ether-spray to the spine, as employed by Lubilski, Zimberlin, 
and others, is also an excellent adjuvant. Its effect is immediately 
quieting, and it may be used two or three times a day for five or six 
minutes along the whole length of the spine. 

In the paroxysmal forms of chorea, ether or chloroform by inhala- 
tion is often necessary to cut short or prevent an immediate seizure, 
but in other respects the treatment mentioned is entirely applicable. 

In all cases hygienic measures are of the utmost importance. Ex- 
ercise in the open air is indispensable ; the food should be of the most 
nutritious character ; the bedroom should be well ventilated ; bathing 
should be frequent ; the bowels should be kept well regulated ; and 
the child, if at school, should be at once removed, and all study for 
the time be interdicted. Ridicule or threats, so often indulged in 
toward choreic children, generally do harm, but at the same time 
they should be encouraged to use all reasonable effort to prevent a 
bad habit being formed. In the epidemic variety of the disorder, 
threats, and even strong repressive measures, are, on the contrary, 
decidedly beneficial in curing and arresting the further progress of the 
disease. 

It is certainly advantageous to keep the patient mentally and phys- 

1 " Du traitement de la choree specialment par l'arsenic et les injections du liqueur de 
Fowler," Paris, 1879. 



HYSTERIA. 727 

ically in a state of comparative repose, but I have never obtained any 
beneficial effect from confining him to bed in a dark room, as recom- 
mended by some writers. On the contrary, I have several times seen 
the disorder aggravated by this measure. It is one that is particularly 
distasteful to most children, and hence keeps them in a continual state 
of fretfulness and excitement. Moreover, it is a measure decidedly 
antagonistic to the general good health of the patient, who requires 
light and fresh air as influential hygienic factors in bringing about a 
favorable result. As regards mental occupation, hard study is of 
course to be avoided ; but I do not think it advisable to prohibit the 
reading of such books as amuse, without requiring any considerable 
degree of intellectual effort for their understanding. 



CHAPTER V. 

HYSTERIA. 

A large volume might be written on hysteria — and many such 
have been published — and there would still be points in its clinical his- 
tory unconsidered. It is difficult, therefore, in a general treatise like 
the present, to give a full view of a disease which plays so important a 
part in nervous pathology, and which is so varied in its manifestations. 
The most that I can hope to do is to lay down certain broad principles 
and features, and leave the recognition of details to the intelligence and 
discrimination of those who read this work. 

Symptoms. — The phenomena of hysteria may be manifested, as re- 
gards the mind, sensibility, motility, and visceral action, separately or 
in any possible combination. Thus it is not uncommon to meet with 
cases in which the only evidence of the disease is seen in abnormal 
mental action ; others are characterized solely by derangements of sen- 
sibility, such as hyperesthesia or anaesthesia ; others by aberration of 
the faculty of motion, such as paralysis, spasms, contractions. Again, 
all of these categories may be witnessed in the same person, giving 
rise, among other phenomena, to coma and convulsions ; and again, 
some one or more of the viscera may be deranged in their functions, 
and thus the appearance of organic disease be simulated. 

As there is such a marked want of uniformity in the character cf 
hysteria as it affects different persons, I will not endeavor to present a 
typical case of the disorder, but will consider separately the principal 
phenomena which may have an hysterical origin. But, in setting out 
to make the attempt, I am reminded of Dante's despair at the thought 
of his inability to describe the horrors of the ninth gulf : 



728 CEREBRO-SPINAL DISEASES. 

" Chi poria mai pur con parole sciolte 
Dicer del sangue, e delle piaghe appieno, 
Ch'io ora vidi, per narrar piu volte ? 

Ogni lingua per certo verria meno, 
Per lo nostro sermone, e per la mente, 
C'hanno a tanto comprender poco seno." 

The Hysterical Diathesis. — Though it is very common to hear the 
hysterical diathesis or temperament mentioned by medical authors, I 
have never been able to recognize its existence by any external traits. 
The fact that it has been so very differently described by writers, from 
Hippocrates and Galen to our own day, is good evidence that it is not 
readily detected. 

Thus, Hippocrates and Galen recognized the existence of the hys- 
terical temperament, but each gave it different characteristics. Lou- 
yer-Villermy 1 had very decided views of its features, and he described 
it as follows : 

" Every hysterical woman is stout, short, dark, plethoric, full of life 
and of health. The complexion is brunette and ruddy, the eyes black 
and sparkling, the mouth large, the teeth white, the lips of a carnation 
red, the hair luxuriant and of the color of jet, the sexual organs well 
developed, and the spermatic liquid abundant." 

Aside from his physiological error relative to the spermatic liquid, 
these are the characteristics of the women of the south of Europe. If 
he had lived in the north, where hysteria is fully as common, he would 
have found that his description of the hysterical temperament would 
not have held good. Indeed, Sydenham, Whyte, Copland, and other 
English authors, represent the hysterical predisposition with almost the 
very opposite characteristics. As Briquet 2 remarks, there is no hyster- 
ical constitution appreciable by the study of external appearances. 
The disease takes women as it finds them, blondes, brunettes, stout, 
thin, strong, weak, ruddy, or pale, there is no choice. Some hysterical 
women have delicate figures and intelligent minds, but there are others 
whose dull, stolid faces give evidence of their stupidity ; and others, 
again, whose thin, fleshless, and wan faces tell us that the Greek type 
of female beauty is not to be regarded as predisposing to the develop- 
ment of hysteria. 

While, therefore, admitting the existence of the hysterical diathesis, 
I know of no marks by which its presence can be determined, other 
than the acts of the patient, which go to make up the clinical history. 

Mental /Symptoms. — These are very various, but generally consist 
in emotional disturbance, an inability or indisposition to exert the will, 
and in the existence of illusions, hallucinations, or delusions. Attacks 

1 Quoted by Briquet, "Traite clinique et therapeutique de rhysterie," Paris, 1859, 
p. 91. 

2 Op. cil. t p 92. 



HYSTERIA. 729 

are often characterized by no other prominent symptoms than those 
connected with mental action, and they may assume every possible 
character. At times, the patient is depressed in spirits, and sheds tears 
profusely ; a few minutes afterward, she has forgotten her grief, and 
laughs immoderately, without adequate cause. Sometimes she laughs 
and cries at the same time. 

Or, there may be a total insusceptibility to any emotion, a listless 
insouciance, which contrasts strongly with her natural disposition. Or, 
again, an emotion the exact opposite of the proper one is excited. This 
is quite a common form of manifestation. A mother, for instance, is 
informed that her daughter has contracted an improper marriage, and 
is immediately seized with immoderate laughter, and shows every ex- 
pression of pleasure, when the rest of the family are overwhelmed with 
grief and shame. Another draws the chief prize in a lottery, and be- 
gins at once to cry and wring her hands. A third, hearing that bur- 
glars have entered the house and have stolen all her jewelry and silver, 
sits stolidly in her chair, her hands folded in her lap, and her whole ex- 
pression indicating the most complete indifference. During either of 
these conditions, she may be entirely silent, or excessively voluble, or 
she may exhibit other hysterical phenomena. 

As regards the will, the manifestations of disorder are sometimes 
very remarkable. That the patient is, for the time being, unable to 
exert it, is evident, but, under the influence of some strong exciting 
cause, she frequently astonishes those about her by suddenly reacquir- 
ing her lost volitional power. 

A young lady came under my charge for what was supposed to be 
a disease of the spinal cord. She had taken to her bed suddenly, soon 
after striking her back rather gently against the edge of a table, declar- 
ing that she could not walk. On examination, I was convinced that 
there was no disease whatever of the spine, other than that of a purely 
hysterical character, and I so expressed myself to her. She, neverthe- 
less, insisted upon it that her spine was seriously injured, and she con- 
tinued to keep her bed, lamenting daily her sad fate at being compelled 
to pass so long a time shut out from the enjoyments of life. There was 
no paralysis or even simulation of it, for she moved her legs about 
freely enough in the bed. But, one evening, her brother, who had long 
been absent, returned home. She heard the bustle in the house attend- 
ant upon his arrival, but all were too busy to pay any attention to her 
in her chamber up-stairs. Suddenly exclaiming, "I can stand this no 
longer," she sprang from her bed, rang for her maid, and, hurrying on 
her clothes, proceeded down-stairs and entered the drawing-room, to 
the great surprise of all the family. 

In another case, a lady closed her eyes, and declared that she could 
not open them. She was brought to me as a case of double ptosis. 
There was no spasm of the orbicularis palpebrarum on either side, and 



730 CEREBRO-SPINAL DISEASES. 

I had no difficulty in opening the eyes by gently raising the lids. The 
pupils were normal; there was no diplopia, and there were no evidences 
of such cerebral lesions as are generally met with as causes of ptosis. 
Moreover, she was subject to paroxysms of hysterical syncope. Under 
the circumstances, I had no hesitation in expressing my opinion to her 
friends that the case was one of hysteria. I advised the use of the in- 
duced current to the eyes, and she found this so disagreeable, not to say 
painful, that two applications were sufficient to restore her volitional 
power, so that she opened her eyes without difficulty. 

In my remarks on aphasia, I have cited a case (p. 182) in which the 
power to speak suddenly returned under the influence of excitement, 
and was suddenly lost again, to be gradually recovered. 

Many cases of this loss of volition in hysteria have been under my 
care, and most physicians have witnessed similar instances. 

Illusions are very common phenomena of hysteria, and these may be 
connected with any or all of the senses. A ball rolling over the floor 
is taken for a rat; the sound of rain falling on the roof is mistaken for 
the noise of burglars in the next room; the knives used at table all 
" smell fishy; " every thing tastes sour or bitter or sweet, as the case may 
be, and a draught of cold air on the hand is supposed to be the touch of 
a person or a spirit. 

Hallucinations of various kinds are equally frequent. Images are 
seen where there is nothing; voices are heard where there is absolute 
silence; odors are smelt where there is nothing to smell; and strange 
tastes are perceived when the mouth is empty. 

Thus one patient sees angels, another demons, another animals of 
various kinds. One hears voices whispering to her, another musical 
sounds, and another noises like the breaking of glass or dishes. Another 
is constantly sensible of a smell as if something is burning, and another 
always has a taste of turpentine in her mouth. 

It is not often the case that these erroneous perceptions impose on 
the intellect, but sometimes they do, and then delusions are enter- 
tained, or these may, as in cases of absolute insanity, be formed with- 
out the intervention of the deranged perceptive faculties. They differ 
however, from the delusions of insanity, such as have been already 
described, in the facts that they do not last long and that they rarely 
exercise any powerful influence over the actions of the patients. 

Besides these mental phenomena indicative of cerebral disturbance, 
there are, sometimes, an extraordinary acuteness of understanding and 
readiness at reasoning and speech quite beyond the natural powers of 
the patient. At other times, on the contrary, the intellect is dulled, 
and the conversational power reduced to a low point. 

Sensibility. — This may be affected so as to result in the production 
either of hyperesthesia or anaesthesia. 

Hyperesthesia, caused by hysteria, is characterized by the facts that 



HYSTERIA. 731 

it is never permanently fixed in one place, that it is generally exces- 
sively acute, and that it is unaccompanied by evidences of serious dis- 
ease of the nervous centres or the nerves. A common seat is the skin, 
and its favorite region is the trunk, especially the skin over the mam- 
mary glands, and that covering the labia majora. Another situation 
frequently affected is the skin of the face. 

Cutaneous hyperesthesia may consist either of spontaneous pain or 
of tenderness to impressions made upon the surface of the body. Mus- 
cular hyperesthesia, or myalgia, is likewise common. Dr. Inman ' has 
investigated this branch of the subject very carefully, and has ascer- 
tained that the painful spots correspond to the origins and insertions 
of the muscles. 

Muscular pains due to hysteria are often mistaken for pains of the 
viscera. Thus the headache which is so frequent a phenomenon of the 
hysterical condition is very seldom located within the cranium. It may 
be of very limited extent, constituting the form known as the clavus 
hystericus, or may be of more extensive limits. Its ordinary situations 
are the frontal regions, occupying, in this case, the occipito-frontalis 
and corrugator supercilii muscles ; the temporal regions, being then 
located in the temporal muscles; the vertex, being then seated in the 
tendon of the occipito-frontalis muscle; and the occipital region, in the 
occipito-frontalis, trapezius, splenius, and complexus. Briquet states 
that, of three hundred and fifty-six hysterical patients whom he ques- 
tioned on the subject, three hundred were constantly subject to head- 
ache. I have very rarely met with a case of hysteria in which it was 
not almost constantly present, and never one in which it was not a 
symptom at some time or other. 

Pains are often felt in the muscles of the chest, abdomen, and back. 
This latter is a favorite situation, especially in the region between the 
shoulders, and in the muscles on each side of the vertebral column in 
the lumbar region. 

Pains in the joints are common manifestations of hysteria, and they 
are often mistaken for serious organic disease. When, as is sometimes 
the case, they are accompanied with contractions of the muscles, the 
liability to error on the part of the practitioner is increased. Sir Ben- 
jamin Brodie, 2 several years ago, pointed out the true nature of certain 
affections of the joints occurring in hysterical women ; and, since his 
time, others, among whom Barlow 3 and Skey 4 are to be mentioned, 
have called special attention to the subject. The pain may be attended 
with swelling, but there is no accumulation of fluid in the cavity of the 

1 " On Myalgia : its Nature, Causes, and Treatment, etc.," London, 1860. 

2 "Illustrations of Certain Local Nervous Affections," London, 1837. 

3 "A Treatise on Diseases of the Joints," London. 

4 " Hysteria, etc. Six Lectures delivered to the Students of St. Bartholomew's Hos- 
pital, 1866," London, 1867. 



732 CEREBRO-SriNAL DISEASES. 

synovial membrane. The knee is more frequently affected than any 
other joint. 

Quite recently a young lady has been under my charge whose knee 
had been for two years kept in a steel apparatus for the purpose of 
preventing motion. Careful examination convinced me that this was a 
case of hysterical joint. I therefore flexed and extended the limb 
several times to its utmost limits, told her to throw away the steel 
rods, and to walk on the leg as much as she pleased. Within six months 
she walked as well as she ever had, and was even able to waltz with 
ease, with no other treatment than daily passive movements of the 
joint. 

In regard to these neuroses Meyer ' has lately communicated much 
interesting information, and has indicated the leading phenomena which 
suffice to distinguish them from organic diseases. Thus the pain ceases 
at night, light handling is more painful than severe pressure, transient 
swellings are apt to occur, the temperature of the part is subject to 
changes, there is no tendency to atrophy of the muscles in the vicinity, 
and they are often cured spontaneously, or by prayer, or by sudden 
movements of the joint, or by some powerful physical cause. 

Neuralgia often has a hysterical origin, and may be in the form of 
toothache, pleurodynia, sciatica, or pain in the course of any other nerve. 
The viscera are likewise frequently hyperaesthetic; the stomach, bowels, 
the kidneys, bladder, uterus, and ovaries, are the organs most frequently 
affected. And of these the most common seat of hyperesthesia in hys- 
terical women is the ovary, and, according to Chairou, 2 the left ovary more 
frequently than the right. I have several times succeeded in causing 
hysterical attacks by moderate pressure on the ovary, and have rarely 
failed to find one or both the seat of marked tenderness in cases of the 
affection. Indeed, so common is it to find ovarian tenderness in hys- 
terical women, that I am almost disposed with Chairou to regard this 
condition as a pathognomonic sign. Charcot 3 also lays great stress 
on the symptom. 

The organs of the special senses rarely escape having their sensi- 
bility exalted, and, consequently, there are increased power of vision, 
morbid acuteness of hearing, and an abnormal sensitiveness of the 
smell and taste. Sometimes with these hyperaesthetic conditions there 
is pain. 

Ancesthesia. — Though not so common as hyperesthesia, ansesthesia 
is frequently a manifestation of hysteria. One of its most common seats 
is the skin. In the days of witchcraft, many a hysterical woman with 
anaesthetic spots on her skin, went to the gallows or the stake on sus- 

1 Berliner klinische Wochensdiri/t, No. 26, 1874. Also Psychological and Medico- 
Legal Journal, September, 1874. 

2 " Etude? cliniques sur la hysterie," Paris, 1870, p. 7. 

3 Op. cit . p. 283. 



HYSTERIA. 733 

picion of being leagued with the devil. The belief was that, wherever 
the hand of the arch-fiend or his assistants touched the skin, the spot 
at once lost its sensibility. 

Two patients are now under my charge in whom there is hemi-anses- 
thesia, paroxysmal in its character. When it is at its height, no irri- 
tation applied to the skin is felt, not even the wire brush of a powerful 
induction-coil. In neither case are the attacks preceded or accompanied 
by numbness. 

Sometimes the location is very limited, and the loss of sensibility 
may be partial or complete. In the former case there is numbness, 
and the full extent can only be exactly ascertained by the aesthesi- 
ometer. 

The mucous membranes may become anaesthetic. One frequently 
affected is that which lines the genital canal. In such a case, the sexual 
passion is entirely extinguished, coition is unattended with pleasure, 
and may even excite disgust. 

The organs of the special senses may be the seat of anaesthesia, and 
thus blindness, deafness, loss of the senses of smell and of taste, may 
be caused, more or less complete in character, in different cases. 

Chairou * has, however, shown that in all cases of hysteria the reflex 
excitability of the larynx is abolished. If in a hysterical woman the 
finger be passed down the throat so as to be brought in contact with 
the epiglottis, it will be found that this part is absolutely insensible, 
and that it can be rubbed or even scraped with the nail without caus- 
ing irritation of any kind. Or the superior orifice of the larynx may be 
similarly treated with the finger or with a probang, a feather, a roll of 
paper, or any similar instrument, without exciting either cough or efforts 
to vomit. 

Since becoming acquainted with Chairou's observations I have inva- 
riably made such an operation as that described a part of my examina- 
tion of hysterical persons male or female, and have never failed to 
verify his statements. It is somewhat astonishing that his observations 
have attracted so little attention. 

Anaesthesia of the muscles is occasionally met with, and has, at 
times, been the occasion of much discussion in medical and theological 
circles. Many of the phenomena observed in the Jansenist convulsion- 
naires were the result of muscular anaesthesia. In an essay a recently 
published, I have called attention to the symptoms, and have adduced 
several cases from the records of my own experience. The extent of 
the anaesthesia is sometimes remarkable. In some of the cases that 
have been under my care, the most powerful induced currents which it 
was safe to use, .failed to cause pain in the muscles to which they were 
applied. 

* Op. dt., p. 12. 

2 " On Certain Conditions of Nervous Derangement," New York, 1881. 



734 



CEEEBRO-SPINAL DISEASES. 



Alterations of Motility. — These may be evidenced in the way of 
paralysis or of clonic or tonic spasm. 

Hysterical paralysis has long been known, and is quite a common 
manifestation of the affection. It may appear in the character of hemi- 
plegia, paraplegia, or of much more restricted extent. I have a case, 
now under care, in which it is limited to the index-finger, and I have 
had several in which a single muscle of the eyeball, or in which the leva- 
tor palpebrse superioris, was alone affected. 

Hysterical aphonia is due to paralysis of one or more muscles of the 
larynx. Like the loss of power in other muscles from a similar cause, 
it often comes on very suddenly, and as suddenly disappears. 

Paraplegia, hysterical in its character, may be partial or complete 
as regards a muscle, group of muscles, or a limb. When incomplete, 
the patient, if it involves the lower extremities, drags her limbs slug- 
gishly along, or shuffles her foot over the floor, using a cane or crutches 
or holding on to articles of furniture that may be in the room. There 
is nothing about the gait like that of locomotor ataxia or, in fact, of 
any other of the diseases of the cord already considered ; and careful 
observation will generally reveal the fact that, during one interview 
and examination, the patient walks very unequally, according to the 
state of her mind at the time, or the influences which act upon her. 

Spasms may be either tonic or clonic, and may affect any muscle of 
the body. In the pharynx, tonic spasm causes the sensation to which 
the term globus hystericus is applied, and which gives rise to the sen- 
sation of a ball in the throat. In the oesophagus, spasm may continue 
for a long time, and may thus simulate stricture. It may also be seated 
in the stomach, intestines, or bladder. 



Fig. 102. 




In the limbs spasm of the tonic character causes contraction, and 
thus, especially when combined with paralysis, may give the appear- 



HYSTERIA. 735 

ance of organic lesion. • I have frequently known hysterical contrac- 
tions to last several months at a time, and have had many cases of the 
kind under my charge in which the actual cautery had been applied 
to the back for supposed inflammation of the cord. 

In some cases the duration is even longer than this. Charcot 
cites an instance in which a woman, aged fifty-five, was seized, eight- 
een years previously, with a hysterical paroxysm followed by para- 
plegia and contraction. At first this latter phenomenon disappeared 
from time to time to reappear again and again, but for the past six- 
teen years there had been no change. The extensors and adductors, 
as will be seen from the accompanying woodcut (Fig. 102), are the 
muscles mainly affected. The muscles of the legs and thighs were 
notably atrophied, and the faradaic contractility was lessened. For 
several years this patient had ceased to exhibit hysterical phenomena. 

The subject of permanent hysterical contraction is well considered 
by MM. Bourn eville and Voulet, 1 and the foregoing case is detailed at 
length in their memoir. In such instances there is probably, as in 
Case XIII. of their work, in which there was a post-mortem examina- 
tion, and which has already been cited in this treatise (page 551), 
symmetrical lateral spinal sclerosis. 

Clonic spasms simulate chorea or epilepsy. They are especially 
common among the women who attend spiritualistic gatherings, and 
indeed I have seen several cases at such places among the weak-minded 
men who believe in the nonsense called spiritualism. 

The functional actions of the viscera are exceedingly liable to de- 
rangement in hysteria. Any organ of the body may be affected, but 
the stomach appears to be the favorite one. There may be obstinate 
vomiting, or persistent flatulence, or acidity, or indigestion in some 
other form ; or the bowels may be the seat, giving rise to intestinal in- 
digestion, diarrhoea, or obstinate costiveness ; or the kidneys may be 
involved, and there may be an enormous secretion of pale, limpid urine, 
or the quantity may be reduced to a minimum ; or the uterus or the 
ovaries may be the seat. Not infrequently organic disease of the heart 
is simulated, there being palpitation and general irregular action of 
this organ. 

Besides these several manifestations of hysteria, there are parox- 
ysms of the disease, characterized by emotional disturbance, spasm, 
convulsions, partial loss pf consciousness, and sometimes coma. All 
these phenomena may be manifested during an attack, or a seizure may 
consist of any one or more of them. The convulsions sometimes bear 
a resemblance to epilepsy, sometimes to tetanus, sometimes to hydro- 
phobia, sometimes to catalepsy, sometimes to chorea. But, though 
simulating these diseases, the essentially hysterical paroxysm can be 
readily distinguished from either of them, mainly by the facts of its 
1 "De la contraction hysterique permanente," Paris, 1872. 



736 CEREBRO-SPINAL DISEASES. 

lack of consistency, the absence of the constitutional disturbance 
which attends the others, and by the presence of emotional excite- 
ment, and the consequent irrational laughing or crying. Attention 
will be again directed to some of these conditions in the ensuing 
chapter. 

Mania may be simulated, but the false can scarcely be mistaken for 
the real disease by any practitioner with his wits about him. 

Causes. — Of the predisposing causes, sex stands first. Of the many 
cases of hysteria which have been under my charge or seen by me in 
consultation, but four were in males. In one of these the affection 
was apparently induced by excessive study, and was characterized by 
frequent paroxysms of laughing and crying. One was a physician, 
and the disease took the form of coma ; one was a lawyer in this city, 
the disease in him simulating epilepsy ; and the fourth was a shop- 
keeper from New Jersey, who had tetanoid paroxysms attended with 
fits of sobbing, crying, and laughing, and in whom it was excited by 
masturbation. 

But, while there is this great predominance of females as the sub- 
jects of hysteria, I do not believe that the fact is always due to any 
particular influence of the uterus or other generative organs. It is 
probably the result in many instances of the delicacy of organization, 
and the greater development of the emotional system, acted upon by 
the exciting causes to be presently mentioned. 

Age is another predisposing cause. The period of life at which 
hysteria is most common is that extending from sixteen to twenty-five. 
After the latter age there is a gradual decline until the age is reached 
at which the menstrual function begins to become irregular, and then 
the number of cases increases. 

The civil condition, as regards marriage or celibacy, is to be taken 
into consideration among the predisposing causes. Undoubtedly the 
disease is much more frequent among the single than the married, but 
it is by no means confined to them. In my opinion the increased pro- 
clivity of single women to hysteria is not to be attributed to ungrati- 
fied sexual desires, or even to the non-fulfillment of the functions of 
the generative organs, but rather to that lack of aims in life, and the 
consequent reflection of the thoughts and emotions upon self, which are 
so inseparably connected, with the present condition of single women. 
Certainly those celibates who have made for themselves objects in ex- 
istence are no more subject to hysteria, in my experience, than married 
women. Want of occupation is one of the powerful predisposing causes 
of hysteria, and it is to a great extent through the direct influence of 
this factor acting upon a more impressionable organization that, in my 
opinion, hysteria is more common in women than in men. In those 
savage and semi-savage countries where women work, hysteria is un- 
heard of. It used to be almost unknown among the negro women in 



IIYSTERIA. 737 

the South, but since their emancipation, if my inquiries have ascertained 
the truth, it is becoming quite common among them. 

Hereditary influence is undoubtedly an important predisposing cause 
of hysteria. My own statistics are not complete on this point, but they 
are full enough to show that the majority had either hysterical mothers, 
aunts, or grandmothers, and many of the others had relatives affected 
with other nervous diseases. Briquet speaks very emphatically of the 
decided influence of hereditary tendency as deduced from his inquiries. 

The luxurious habits of life attendant upon refinement and educa- 
tion conduce to the development of hysteria. Attendance at theatres 
and operas, the cultivation of music, the reading of poetry and novels, 
the study of art, and any other influence capable of developing the emo- 
tional system at the expense of the purely physical or intellectual, fa- 
vor the growth of hysterical tendencies. 

Of exciting causes, sudden emotional disturbance ranks first. Anx- 
iety, grief, disappointment, the intense desire of self-gratification, a fit 
of ill-temper, with other similar factors, often induce paroxysms of the 
disease. Mental or physical fatigue, menstrual derangement, or uterine 
or ovarian disorders, may also act as exciting causes. 

But probably, above all these, is the contagion set in action by the 
contact with a hysterical person. I have seen a whole hospital ward 
of women thrown into paroxysms of hysteria by one patient suffering 
from an attack. 

Diagnosis. — To detail the diagnostic marks which distinguish hys- 
teria from other diseases would require more space than is proper in a 
work like the present, and would, moreover, be rather a work of super- 
erogation. The physician has simply to recollect that all hysterical 
affections have a family resemblance, and that, although almost every 
known disease may be simulated, yet that the counterfeit is never a 
good one. Attention to the symptoms of the several diseases already, 
and to be described, with a careful observation of the case, and due 
inquiry into the antecedents of the patient, will prevent a mistake be- 
ing made. 

He must also recollect that the hysterical patient always tries to 
impress others with the belief that she is very ill. She craves sym- 
pathy, and feeds on it with the effect of nourishing her disease. If she 
can cajole her medical attendant by appealing to his kindly emotions, 
she will do it, but failing in this she will try her power over his fears, 
and will leave no stone unturned to deceive him. Careful watching, 
with thorough skepticism, will either result in her detection, or in her 
defeat from sheer weariness. 

Prognosis. — As regards the prospect of recovery from any particular 
manifestation of hysteria, or from a paroxysm of any kind, the prog- 
nosis is favorable, provided proper treatment be employed, but, as re- 
gards the liability to further attacks, much depends on the circum- 
48 



738 CEREBRO-SPINAL DISEASES. 

stances which surround the patient and the time during which she has 
been subject to the affection. If she can be submitted to proper treat- 
ment, without the interference of herself or her friends, the prospect of 
recovery, even in bad cases, is good ; but if she is to be allowed to do 
as she pleases, or if injudicious friends are constantly lavishing the sym- 
pathy and mistaken kindness which keep her disease alive, there is not 
much use in medicine or hygiene, and, as Reynolds says, the " case is 
hopeless, and might as well be left alone." 

Morbid Anatomy and Pathology. — Hysteria contributes absolutely 
nothing to the science of morbid anatomy. The brain, the spinal cord, 
the sympathetic nerve, give no evidence of its former presence. It is 
true, hysteria very rarely causes death, but hysterical patients have 
died of intercurrent affections, and post-mortem examinations have been 
made, and nothing which could reasonably be regarded as the essential 
cause of the disease has been found. Several of the older writers im- 
agined that they had discovered the lesion in the genital organs, in the 
stomach and intestines, in the brain, and even in the spleen ; but mod- 
ern research teaches us differently. At present, then, we are in total 
ignorance of the character of the lesion. From the symptoms, which 
are so obviously indicative of disordered brain and spinal cord, I have 
felt myself justified in classing it, provisionally at least, among the cere- 
brospinal diseases. 

The pathology or morbid physiology of hysteria is beginning to be 
better understood as our knowledge of the cerebral and spinal actions 
becomes more complete. Looking at the brain as a complex organ evolv- 
ing a complex force — the mind — we can understand the possibility of 
certain parts of it becoming disordered, as regards excess, diminution, 
or quality, in the results of their actions. We have seen, under the 
head of insanity, that' the mind is made up of certain sub-forces — the 
perception, the intellect, the emotions, and the will — and that these, 
when disordered, constitute varieties of insanity, which are easily recog- 
nized. 

Hysteria essentially consists in the predominance of the emotions 
over the intellect, and especially over the will, and this exaltation may 
be so intense as to interfere with the sensibility of various parts of the 
body, or to derange the contractility of muscles. 

At the same time, in the paroxysms of the disease, the reflex and 
automatic functions of the spinal cord are involved to a great extent. 

We daily witness examples of the influence of emotions on sensi- 
bility and motility. Fear renders the sensibility more acute and pro- 
duces trembling, which is simply clonic spasm ; grief causes tonic con- 
tractions of the muscles ; surprise, terror, or horror, paralyzes them ; 
joy or anger destroys sensibility to pain, and so on. 

At the same time that there is this exaltation of emotional power in 
hysteria, the power of the will is not only relatively but is absolutely 
diminished. The two factors, acting together steadily and persistently, 



HYSTERIA. 739 

induce many of the manifestations of hysteria. The disease is, there- 
fore, a partial insanity — an insanity, however, in which the patient does 
not entirely lose the power of control, and which is capable of being 
overcome by the voluntary effort of the patient, provided a sufficient 
stimulus to normal volition be brought to bear. It thus happens that, 
through the influence of such stimulus, every symptom of hysteria dis- 
appears as if by magic. 

The spinal cord is often secondarily affected, and it is likewise fre- 
quently primarily involved. The gray or the white substance, the pos- 
terior or the antero-lateral columns may be implicated, the symptoms 
varying accordingly. Through the spinal cord, in its abnormal condi- 
tion, we have the convulsions of various kinds, the spasms, contrac- 
tions, and the paraplegic and hemiplegic phenomena connected with 
motion and sensation. 

As to the influence of the vaso-motor s}-stem, though I admit its 
existence, I am convinced that it is simply a link in the chain, and is 
secondary to the emotional disturbance already mentioned. 

Treatment. — No cases are so well calculated to test the patience and 
tact of the physician as those of hysteria. For he has an affection to 
deal with, which not only requires proper medical treatment, but in 
which he must often exert the highest mental qualities, in order to cure 
the disease. A great deal, therefore depends on the knowledge of hu- 
man nature and the force of character of the physician ; and it is doubt- 
less owing to this fact that some physicians, with all their medical 
knowledge, fail in curing hysterical affections, while others, with no 
superior science, succeed at once. 

The first thing to be done is to gain the confidence and, what is of 
still greater importance, the respect of the patient. Having done this, 
any treatment, moral or medical, calculated to relieve her, will be much 
more apt to produce the desired effect. 

During the period between the paroxysms, the treatment must be 
directed mainly against symptoms. If the patient can be made to be- 
lieve that her case is thoroughly understood, and that she is not sus- 
pected of shamming, and that, with her assistance, the hyperaesthesia, 
or anaesthesia, or paralysis, will be removed, the effect which is desired 
will probably be produced. For putting a hysterical patient into a 
proper frame of mind, I know of nothing equal to the bromides, of either 
potassium, sodium, calcium, or zinc, given in large doses, repeated three 
or four times a day, till the full effect is obtained. This will generally 
relieve hyperaesthesia wherever it may be seated, and the influence over 
the mental phenomena of the disease is usually very decidedly shown. 

If anaesthesia be the prominent condition, electricity is to be used, 
and it is almost a specific. I have never seen a case of hysterical an- 
aesthesia resist it. A few days ago, I was consulted by a young lady 
who w T as entirely anaesthetic over the whole of the surface of one side 
of the body, and who had suffered for several weeks. Three applica- 



740 CEREBRO-SPINAL DISEASES. 

tions of the induced current through the wire brush, which was passed, 
at each seance, over the whole anaesthetic region, entirely cured her. 

For hysterical paralysis, strychnia and phosphorus are the best in- 
ternal remedies. They may be taken together in the form recommended 
on page 68, and rarely fail to produce a cure. Their effect is, how- 
ever, greatly increased by the use of electricity, both of the primary 
and induced forms — the first being applied to the spine, and the latter 
to the paralyzed muscles. 

In cases of spasm, I prefer the bromides, internally, and the primary 
galvanic current, applied to the contracted muscles. 

Visceral derangements are best treated by strychnia and phospho- 
rus, as recommended for paralysis. Counter-irritation, in the form of 
blisters, is almost always of service. For gastric troubles, the subcar- 
bonate of bismuth, in doses of fifteen or twenty grains, after each meal, 
will generally prove of service. In a very obstinate case of hysterical 
vomiting under my charge, everything failed but hydrocyanic acid. 

Recently, in several extreme cases of hysterical vomiting, and nota- 
bly in one I saw in consultation with Dr. C. T. Whybrew, I have ob- 
tained very prompt results from the valerianate of caffeine in doses of 
three grains repeated in a half-hour if necessary. Paret ' adduces sev- 
eral examples of its beneficial effects in like cases. 

In other cases I have arrested hysterical vomiting by giving four 
or five pills of hydrochlorate of cocaine, each pill containing the one 
twentieth of a grain of the drug. 

Hysterical paroxysms are best treated with ether or chloroform, ad- 
ministered by inhalation. I have repeatedly used the hydrate of chlo- 
ral, but it has not in my hands been as speedy or as effectual in its 
action as either of the other agents. I give them to the extent of pro- 
ducing complete insensibility, and repeat them again and again, if there 
are any evidences of a return of the seizure. Whether in the purely 
emotional paroxysms or those characterized by muscular spasms of 
various kinds, or any possible combination, nothing is equal, according 
to my experience, to ether or chloroform by inhalation. I have tried 
every other known means, from cold water, dashed in the face, to 
moral suasion, and none of them are comparable to ether or chloroform. 

I have also found decided benefit from the mono-bromide of cam- 
phor in breaking up what may be called the status hystericus. In a 
recent communication 2 I called attention to its good effects in such 
cases. It may be given in pill or emulsion in doses of from three to 
five grains every hour or two, as may be required. In those cases in 
which ether or chloroform is contraindicated the mono-bromide of cam- 
phor is particularly valuable. 

1 " De l'emploi de valerianate de cafeine," Paris, 1875. 

8 "Note relative to the Mono-Bromide of Camphor," New York Medical Journal, vol 
xiii., 1871. 



HYSTERIA. 741 

But, for the dissipation of the hysterical tendency, long-continued 
treatment is necessary. Medicines which are ordinarily regarded as 
antispasmodics, such as valerian, asafcetida, musk, and the like, I have 
never seen produce any benefit in any form of hysteria, and, for the 
purpose of causing any radical change in the organism, they are worse 
than useless. As medicines for this object, I know of nothing superior 
to phosphorus, in some one of its forms, and strychnia. They should be 
taken for months in small doses, and should be supported by all hy- 
gienic measures calculated to improve the tone of the system. Travel 
is of inestimable advantage, and, above all, association with persons of 
both sexes, whose intellects control their emotions, and who are en- 
dowed with sound common-sense and that tact and knowledge of human 
nature which, for the purposes of every-day life, are of more value than 
many other qualities often ranked above them. 

It is very certain that in most cases of hysteria the exhibition of 
sympathy is exceedingly injudicious and is generally taken advantage 
of by the patient to impose still further on those around her. Thus a 
lady to whom I was called had gotten into a morbid condition attended 
with frequent paroxysms of weeping, because, as she said, she no longer 
cared for her husband or children, and that she wished they were dead, 
etc. All the arguments of her friends failed to convince her that she 
was a good wife and mother, but, on my telling her husband in her pres- 
ence that I was afraid it would be necessary to send her to a lunatic 
asylum, her interest was at once awakened, and the next morning she 
was entirely free from all hysterical phenomena. She subsequently 
told me that nothing had roused her but the fear of being put in a 
hospital for the insane. 

In another case a lady had terrified her friends and excited the 
greatest commotion by threatening to put an end to her life by jump- 
ing out of the window. When I saw her she was strapped down to a 
bed and was being supplicated by half a dozen people in the room not 
to kill herself, to which she was energetically replying that she would. 
I loosened the straps, opened the window, and told her to jump out. 
She walked to the window, looked out for a moment, and then, apply- 
ing no very polite epithet to me, went back to bed, and I heard no more 
of her suicidal desires. 

A still more remarkable case is given by M. Charcot. 1 The pa- 
tient, a woman, had been for at least four years the subject of con- 
traction of one of the lower extremities, as shown in the woodcut 
(Fig. 103). In consequence of her insubordination on one occasion, he 
spoke to her very sharply, and threatened to send her out of the hos- 
pital. The next morning the contraction had entirely disappeared. In 
the face of facts like these it appears absurd to invoke supernatural 
agencies. 

1 "Lemons sur les maladies du systeme nerveux," Paris, 1872-73, p. 31S. 



742 



CEREBRO-SPINAL DISEASES. 



It is, perhaps, scarcely necessary to state that the society of other 
hysterical persons must be rigidly eschewed, and that even the casual 
meeting with such individuals is dangerous. 



Fig. 




CHAPTER VI. 

HYSTEROID AFFECTIONS— CATALEPSY, ECSTASY, HYSTERO-EPILEPSY. 

There are certain disorders so very like hysteria in some of its 
manifestations, and often existing with it in the same individual, that 
they might with propriety have been considered in the last chapter, es- 
pecially as by some high authorities the scope of hysteria is so enlarged 
as to be made to embrace them within its limits. But, though they 
may owe their existence to the same peculiar condition of the nervous 
system, to which the ordinary phenomena of hysteria are due, there 
is sufficient individuality about them to warrant then* being studied 
separate!} 7 . At the same time there will be no difficulty in our bearing 
in mind that they are decidedly of such general and special character- 
istics as to impress us very forcibly with the idea that they are essen- 
tially hysterical. We may, therefore, with propriety, class them to- 
gether in the present chapter as hysteroid. 



CATALEPSY. 



Although there are no post-mortem appearances characteristic of 
catalepsy, the phenomena of the disease observed during life point to 



CATALEPSY. 743 

its seat in the brain and spinal cord. Like epilepsy, therefore, it is 
a symptom representing an unknown morbid change in the nervous 
centres. 

Symptoms. — Catalepsy is an affection marked by the occurrence of 
peculiar paroxysms at regular or irregular periods. The seizures usu- 
ally come on with suddenness, and are characterized by more or less 
complete suspension of mental action and of sensibility, and by the 
supervention of muscular rigidity, causing the limbs to retain, for a 
long time, any position in which they may be placed. The phenomena, 
therefore, relate to the mind, to sensation, and to motion. 

The suspension of mental action is, in general, complete, but in some 
cases there are an imperfect consciousness and an ability to appreciate 
strong sensorial impressions. Thus, in a case quoted by Dr. Chambers 
from Dr. Jebb — which, however, was clearly a case of catalepsy compli- 
cated with hysteria — the patient, before emerging from the paroxysm, 
sang " three plaintive songs in a tone of voice so elegantly expressive, 
and with such affecting modulation, as evidently pointed out how much 
the most powerful passion of the mind was concerned in the production 
of her disorder, as indeed her history confirmed." ' 

The aspect of a cataleptic patient is very striking. The eyelids are 
sometimes wide open, at others gently closed ; the pupils are dilated, 
and do not respond to strong light; the respiration is slow, regular, but 
generally so feeble as to be perceived with difficulty; the pulse is usu- 
ally almost imperceptible, but is rhythmical and sluggish ; the face is 
pale, the mouth is half open, and the rigidity of the body and the cold- 
ness of the extremities add to the death-like appearance which im- 
presses all beholders. 

The cutaneous sensibility is ordinarily completely abolished. Pins 
may be stuck into the skin, and they are not felt ; but, owing to the 
abolition of the power of motion and of reflex action, it is possible that 
in some cases, at least, the patients would give evidence of sensation if 
they could. Cases are on record in which tears have been caused by 
excessive emotional disturbance excited by the words or actions of per- 
sons surrounding the patients, thus showing that the senses of sight and 
hearing were capable of being exercised. Such instances are, however, 
rare, and are probably imperfectly-developed paroxysms, or those com- 
plicated with hysteria or ecstasy. 

The symptoms relating to the muscles are very remarkable. Com- 
ing on, as the paroxysm usually does, without warning of any kind, the 
patient is at once arrested in any act which is being performed, and the 
whole body assumes a condition of extreme rigidity. The power of the 
will over the muscles is lost, and the limbs preserve any position in 
which they may be placed by the by-standers. Thus, if the arm be 
raised from the side, it remains extended, and may keep this position 
1 Article " Catalepsy," in Reynolds's " System of Medicine," vol. ii., p. 100. 



744 CEREBRO-SPINAL DISEASES. 

for an hour or longer before it sinks slowly back to its original situ* 
ation. No matter how awkward or irksome the position may be, it 
is retained till the exalted irritability of the muscles becomes thorough- 
ly exhausted. 

The ability to swallow is not lost, and the electric contractility of 
the muscles is not perceptibly affected one way or the other. 

The paroxysm may last a few minutes or hours, or may be prolonged 
to several days. 

The temperature of the body, in all the cases that have come under 
my observation, was reduced from two to four degrees below the nor- 
mal standard, and in the extremities much more than this. 

The paroxysm generally disappears with as much abruptness as 
marked its accession. A few deep inspirations are taken, the eyes are 
opened, or lose their fixedness, the muscles relax, and consciousness is 
restored. In fully-developed seizures the patient has no knowledge of 
what has occurred during the attack. 

Ten cases of true catalepsy, uncomplicated either with hysteria or 
ecstasy, have been under my professional care. In two of these the 
seizures were more or less imperfectly developed, and strong sensorial 
excitations were, in a measure, perceived and recollected after emer- 
gence from the attack. But in every instance the character of the im- 
pression was misinterpreted. A bright light thrown upon the eyes 
with a mirror was spoken of as an " angel's wing which brushed across 
my face," and the scratch of a pin was remembered as " a piece of ice 
being drawn over the skin." 

In these cases there was the consciousness of mental action during 
the paroxysm, but it was difficult for the patients to describe the 
thoughts which took place. They appeared to be somewhat of the 
nature of dreams. In both cases the muscular rigidity was well marked 
but was not excessive, and appeared to be mainly manifested in the ex- 
tensors. It was not difficult to extend the arm or the leg, but flexion 
required the exertion of a good deal of strength. 

In the other eight cases the paroxysms were completely formed. 
Consciousness was entirely abolished ; there was no sensibility any- 
where, and no reflex actions could be excited except those of degluti- 
tion. In one of these cases, seizures several times occurred in my con- 
sulting-room, and I had the opportunity of ascertaining the effect of 
electricity. If the arm was extended, the strongest induced current I 
could apply to the biceps, though causing contraction, failed to procure 
flexion, but relaxation of the extensors was at once produced by the 
application to them of the galvanic current. 

I likewise, in this case, repeatedly examined the fundus of the eye 
with the ophthalmoscope, and invariably found the choroids pale, and 
the retinal vessels straight and attenuated. 

In none of these cases was there any knowledge of what passed 



CATALEPSY. 745 

during the paroxysms, and no consciousness of there having been any 
mental activity. 

Besides these, several instances have occurred in my experience in 
which cataleptic phenomena were exhibited in the course of other dis- 
eases. In one of them, a young man whom I saw in consultation with 
Dr. Max Herzog, of this city, there was well-marked mania — a second 
attack. On my entering the room in which he was seated I observed 
that he had a rapt expression of countenance, and that his limbs were 
quiet, and apparently rigid. In an undertone I remarked to Dr. Her- 
zog that the patient had a somewhat cataleptic appearance. Seizing 
his arm I raised it from the body and it remained extended; the other 
arm was also elevated and continued in that position. I then lifted 
the legs alternately from the floor, and they were kept in their appar- 
ently uncomfortable positions. During the consultation, probably a 
half -hour, the extremities remained as I had placed them. A few days 
afterward, he became so violent that it was necessary to send him to a 
lunatic asylum. 

In another case the patient, a young lady of this city, was brought 
to me by her father for examination and advice. As she entered my 
consulting-room, I saw that there was a high degree of mental exalta- 
tion present — her eyes were raised to the ceiling, her hands were 
clasped, and her lips were moving as if in prayer. I raised her left arm 
from the body, and then the right ; both remained extended, and con- 
tinued so till I changed the positions, which I did by bending the 
elbows, bringing them to the front, putting them behind her, and so on. 
I then again extended them, and she left the house with them in this 
position; but, on getting into the street, and feeling a cold wind that 
was blowing at the time, they fell to her side and she began to use 
them to draw her shawl aroun4 her. She had been subject to epi- 
lepsy for several months, but had never before exhibited cataleptic 
phenomena. 

In the former of these cases there was no possibility of ascertaining 
the mental associations of the patient with the muscular rigidity; in the 
latter the patient said that she had a very distinct recollection of my 
extending her arms, but why she had kept them so she did not know, 
and that she was not conscious of fatigue, or of any other sensation. 

It will have been noticed that in both these cases the paroxysms 
were not spontaneous, but were excited by outside interference. 

The particulars of a very interesting case of catalepsy have been 
recently given to me by Dr. M. B. Early, late house-physician to Belle- 
vue Hospital. 

The patient, a German, a cigar-maker, aged twenty-three, had served 
in the army, entered the hospital October 4, 1872. In the previous 
July he had been drunk, and, quarreling with some rough people, was 
severely beaten and kicked on the head and other parts of his body. 



746 CEREBRO-SPINAL DISEASES. 

On the 27th of September he had an attack resembling a convul- 
sion. He was smoking at the time, and, while thus engaged, his mother 
noticed that the cigar began to shake, then his whole body quivered. 
She attempted to take the cigar from his mouth, but the jaws were 
tightly closed, and the cigar was bitten through. He swallowed the 
portion that was left in his mouth. He seemed to be conscious, for 
when requested by his mother to go to bed he shook his head. He did 
not sleep, but, when spoken to, nodded or shook his head in assent or 
dissent as the case might be. He did not foam at the mouth or bite 
his tongue. His feet were very cold. 

The attack lasted about five minutes. He then vomited the piece of 
cigar he had swallowed, and went to bed, sleeping all afternoon. 

The following day he had a similar attack, not so severe as the first. 
During the five following days he was free from paroxysms, but would 
not talk, although he ate and seemed to understand what was said to 
him, and would do any little thing his mother requested. On the sixth 
day, soon after breakfast, he had another paroxysm, but of a different 
character from the others. While the previous seizures were charac- 
terized by tremor, this was marked by a rigidity of all the voluntary 
muscles in the body. The attack lasted a few minutes, and the next 
day he was taken to the hospital, where he came under Dr. Early's 
observation. 

On admission, October 4th, he lay in a stupid condition, his eyes 
sometimes open and sometimes closed. Occasionally he looked around, 
and appeared to understand what was said to him, but could neither 
speak nor move. The pupils were dilated. When his limbs were 
placed in any position they continued there for a considerable period. 
The muscles were rigid, temperature 100° Fahr. 

On being slapped smartly on the buttocks with a book, the patient 
got up, looked about him, and walked around the ward. He then drank 
a glass of milk and went back to bed. Just before getting up he 
smiled, and answered a question. During the night he went to the 
water-closet. In the morning he arose, looked around him, and drank 
some more milk. When slapped with a book shortly afterward, he did 
not move a muscle; seemed more stupid, did not swallow when food 
was placed in his mouth, and apparently did not feel the prick of a pin. 

The patient continued in this state for several days. On the 12th 
he was photographed. The accompanying woodcuts, Figs. 104 and 105, 
show the positions of his limbs at the time. 

Under the treatment the patient gradually improved, and on the 9th 
of November was discharged cured. 

An ophthalmoscopic examination, made November 3d, showed an 
anaemic condition of the disk. 

Cataleptic persons are usually of dull and sluggish mental and phys- 
ical organization. Such has certainly been the case in all the in- 



CATALEPSY. 



747 



stances that have come under my observation. The disease does not 
ordinarily show any decided tendency to become worse, either as 
regards the severity or frequency of the paroxysms, providing the ex- 
citing causes be avoided. On the contrary, there is often a well- 



Fig. 104. 




marked natural tendency to spontaneous cure, or at least to a cure 
through the influence of purely hygienic influences, moral as well as 
physical. 

In the majority of cases catalepsy is complicated with hysteria or 



Fig. 105. 




^JH 'I \ 



ecstasy, and sometimes with epilepsy. Of this latter combination I 
have seen two cases, and in one of these ecstasy was also a feature. 
Tins case I have alluded to in another communication. 1 The patient 

1 " The Physics and Physiology of Spiritualism," New York, 1871, p. 55. 



748 CEREBRO-SPINAL DISEASES. 

was a young girl, was cataleptic on an average once a week, and 
epileptic twice or three times in the intervals. Five years previously 
she had spent six months in France, but had not acquired more 
than a very slight knowledge of the language — scarcely, in fact, suffi- 
cient to enable her to ask for what she wanted at her meals. Immedi- 
ately before her cataleptic seizures, she went into a state of ecstasy, 
during which she recited poetry in French, and delivered harangues 
about virtue and godliness in the same language. She pronounced at 
these times exceedingly well, and seemed never at a loss for a word. 
To all surrounding influences she was apparently dead; but she sat bolt 
upright in her chair, staring at vacancy, and her organs of speech in 
constant action. Gradually, she passed into the cataleptic paroxysm, 
in which she usually remained for from one to three hours. Many cases 
of the combination of catalepsy with hysteria and ecstasy have become 
celebrated in other relations than those of true science. 

Causes. — Among the predisposing causes, sex is, in my experience, 
the most efficient, though other writers have denied any influence due 
to sex. Of one hundred and forty-eight cases cited by Puel, 1 sixty- 
eight were males and eighty females. Seven of my cases were in 
females. Hereditary influence is generally apparent. Of the ten un- 
complicated cases under my observation, all had relatives affected with 
some well-marked disease of the nervous system. In four cases, there 
were near relatives insane; in three, the mothers were hysterical; in 
one, a brother was epileptic; in one, the father was similarly affected; 
and, in one, a sister was cataleptic. It rarely begins after the age of 
twenty-five. Of exciting causes, emotional disturbance stands first. 
Four of my cases were directly the result — one of fright, one of anger, 
one of. grief, and one of the shock caused by a boy starting out sud- 
denly from behind a door where he had been concealed. In one other 
case, the cause was worms in the intestinal canal; in two, business 
troubles; in one a severe fall; and, in the other two, I could not ascer- 
tain with certainty what the cause was, though I had strong reasons 
for suspecting it to be masturbation. 

The Diagnosis is not a matter of the least difficulty to any one who 
has even an imperfect knowledge of the phenomena, except, perhaps, 
as regards its discrimination from hysteria, that simulator of almost 
every nervous disease. In those cases complicated with hysteria, the 
distinction is of no importance; in others, the uniformity of the charac- 
teristics which indicate catalepsy, with a consideration of the general 
history of the case, will serve to make the diagnosis sufficiently precise. 
It must, however, be borne in mind that- the two diseases are near of 
kin, and that the discrimination is important more as a matter of ab- 
stract science than as one of any bearing on the therapeutics. It is, 
however, sometimes a matter of moment to distinguish between the 
1 "De la catalepsie," "Meinoires de l'Academie de Medecine," tome xx , 1658, p. 409. 



CATALEPSY. 749 

cataleptic paroxysm and death. In former times, instances were not 
uncommon in which the mistake was made, to be discovered after life 
had really become extinct in the coffin. Such fatal errors would prob- 
ably be impossible now with the stethoscope for examining the heart, 
the thermometer for determining the temperature, electricity for acting 
on the muscles, and, above all, the ability to place the limbs in posi- 
tions which they maintain against the laws of gravity. Moreover, our 
knowledge of diseases in general is such as to enable us to determine 
with great certainty the course they are liable to take, and the manner 
in which death occurs in each. 

Prognosis. — This is usually favorable, even in severe cases. All my 
patients recovered under the treatment to be presently mentioned. 

Morbid Anatomy and Pathology. — There is not much to say relative 
to the morbid anatomy of catalepsy. In some cases in which death has 
taken place, other diseases were present, and the lesions found were 
rather to be associated with them than with catalepsy. 

Puel, 1 in his very elaborate treatise, says that the first report of a 
post-mortem examination of a patient dying while subject to the dis- 
ease in question is that of Hollerius, made in 1596. The patient, a 
man, had but one paroxysm, and died the same day. The lungs and 
liver were gangrenous, a collection of reddish serum was found in the 
posterior part of the brain, and sanguineous concretions (thrombi) in 
the superior longitudinal sinus. 

Deidier, in 1811, reported the case of an elderly man who had but 
one paroxysm, lasting a day, and who died eight days afterward. In 
this instance there were found, on each side of the longitudinal sinus, 
two little glandular bodies which were described perfectly, and to which 
the catalepsy was attributed. These were nothing more than the granu- 
lations of the dura mater, now known as the Pacchionian bodies. 

In a maniac who was subject to catalepsy and who died at Charen- 
ton, in 1834, the report by Georget and Calmeil states that the pia 
mater was found thickened and injected ; the cortical substance of the 
brain was reddened and softened, and the white substance contained 
enlarged vessels. In another case the same observers found the cortical 
substance discolored, and the white tissue injected. As they remark, 
however, these are the lesions of insanity with general paralysis. 

In other cases no alterations which could normally be associated 
with the cataleptic phenomena were discovered. 

The pathology of catalepsy is very imperfectly known. The symp- 
toms indicate that the brain and spinal cord are involved, and there is 
some evidence to show that they are in a state of anasmia. But there 
is a condition induced in these organs which is the essential feature of 
the disease, and of this we know nothing. There is a possibility that 
the affection may be a masked form of epilepsy, and this view is borne 

1 Op. ciV., p. 518. 



750 CEREBRO-SPINAL DISEASES. 

out by the fact that the treatment which is most successful in this lat- 
ter disease is most efficacious in catalepsy. 

But recent researches have served to give us perhaps some inkling 
of the real nature of catalepsy, and to supply us with examples of arti- 
ficially-induced cataleptiform phenomena which are of great interest as 
analogical to instances of the natural disease. The investigations which 
have been made relative to motor centres in the brain lead us to sup- 
pose that there are likewise inhibitory centres in the cerebro-spinal sys- 
tem, probably both in the brain and spinal cord. We often meet with 
cases in which there is complete paralysis of one or more parts of the 
body, and which are suddenly caused by some strong impression pro- 
duced upon the emotions. Now, catalepsy is, for the time being, a pa- 
ralysis of the will, a condition in which, while the muscles have not lest 
their power to contract, there is a loss of volitional influence over them. 
They are still capable of responding to stimulation from without, but, in 
the absence of stimulation from within, they retain whatever degree of 
contraction may be given to them. 

Some of the results which follow experiments made to induce what 
is called the hypnotic state, are very suggestive of catalepsy. A craw- 
fish, as Czermack 1 has shown, can be thrown into the cataleptic condi- 
tion, during which he is rigid and immovable. And I have repeatedly 
put frogs, lobsters, and hens, into a similar state. The full considera- 
tion of these interesting phenomena would be out of place in a practi- 
cal treatise on diseases of the nervous system. 2 

But I may at least state that I have recently developed the most 
intense cataleptoid phenomena in several subjects through the influ- 
ence of suggestion, while they were in the hypnotic, or, as I think it 
should more properly be called, the syggignostic (ovyyiyvuoieb), to 
agree with) condition. Among other exhibitions of the phenomena is 
one which is especially striking. By merely telling the subject that 
his body is so rigid that he cannot bend it, he at once becomes cata- 
leptic in every voluntary muscle, and may then be laid upon the backs 
of two chairs, as shown in the cut (Fig. 106), in which position he will 
remain for several minutes ; then the muscles gradually become unable 
longer to endure the strain, and the body sinks slowly to the floor. 
Very few trained gymnasts could perform this feat at all, and no one 
in his normal state could maintain the necessary muscular tension as 
long as the physically weak young man from whom the drawing is 
made. As is seen, the body rests only on the occiput and on one os 
calcis ; and I have known the position to be steadily kept for full 
five minutes. In these cases there is no excitation of muscular con- 

1 " On Hypnotism in Animals," translated from the German by Clara Hammond, 
Popular Science Monthly, September and November,' 1873. 

2 For a more complete account of the phenomena and physiology of catalepsy, ecsta- 
sy, somnambulism, etc., the reader is referred to the author's work " On Certain Condi- 
tions of Nervous Derangement," New York, G. P. Putnam's Sons, 1881. 



CATALEPSY. 



751 



traction by reflex action, such as is supposed by Charcot and Hei- 
denhain to produce it, but it is induced solely by suggesting to the 



Fig 




subject that his body is in a rigid state. Immediately the muscles 
become tense, and he can be handled like a board. 

There may thus be in catalepsy inhibitory lesions, just as in epilepsy 
there are discharging lesions. But as in this latter disease there is 
something more than the convulsive movements, so in catalepsy there 
is a morbid element in addition to the muscular inhibition. And this 
appears to be an overwhelming inclination to agree with the sugges- 
tions received from other persons. Catalepsy is therefore hypnotism 
— or, as I prefer to call it, from its main characteristic, syggignoscism 
— with the addition of phenomena of muscular rigidity. Any syggi- 
gnostic subject can be thrown into a cataleptic condition, and the cata- 
leptic patient can readily be made to exhibit the ordinary manifesta- 
tions of syggignoscism. 

Treatment. — The bromide of potassium, or one of the other bro- 
mides previously mentioned under the head of epilepsy, is the most 
efficient agent in the treatment of catalepsy. I have never yet failed 
to cure the disease with this remedy, combined with the oxide of zinc, 
and with the simultaneous use of strychnia and other tonics. I have 
never, however, had occasion to give it in larger doses than twenty 
grains, three times a day, or to continue it beyond eight months. 

In no disease of the nervous system, not even excepting hysteria, is 
it more necessary that the mind should be brought under proper disci- 
pline, and kept as far as possible from the operation of all causes calcu- 
lated to promote emotional excitement. At the same time, a well- 
regulated system of hygiene, as regards all the physical requirements 
of the body, is indispensable. 



752 CEREBRO-SPINAL DISEASES. 



ECSTASY. 

Though closely allied to catalepsy, ecstasy differs from it in several 
important particulars. One of the main points of difference is, that the 
patient recollects the train of thought which has been going on during 
the seizure, and this of itself is sufficient to warrant their being sepa- 
rately considered. It often happens, however, that the two diseases 
alternate or coexist. 

Symptoms. — In ecstasy there is muscular immobility rather than 
rigidity, although the latter is sometimes present ; the eyes are open, 
the lips parted ; the face is turned upward, the hands are often out- 
stretched ; the body is erect and raised to its utmost height, or else is 
extended at full length in the recumbent posture. A peculiar radiant 
smile illumes the countenance, and the whole aspect and attitude is that 
of intense mental exaltation. 

The mind is so filled with some particular train of thought, that ex- 
citations of the senses, if of moderate intensity, are not perceived. We 
meet with this fact often in normal conditions, when the mind is deeply 
engaged in reflection, or when it is engrossed with some powerful emo- 
tion. 

Sometimes there is complete silence, the mind being apparently ab- 
sorbed with meditation or with the contemplation of some beatific vision. 
Again, there may be mystical speaking, prophesying, singing, or the 
lips may be in motion as if in speaking, but without any sound escap- 
ing. _ . 

At times various attitudes are assumed which are in consonance 
with the ideas passing through the ecstatic's mind. Again, stigmata 
or spots of blood appear in the hands or other parts of the body, and 
which are supposed to represent the wounds made by the nails in the 
hands and feet of Jesus, or the thrust of the spear in his side ; and, 
again, a real or assumed abstinence from food exists. 

Among the ecstatics of a former period, St. Francis of Assisi, St. 
Catherine of Sienna, St. Theresa, Joan of Arc, and Madame Guyon, are 
to be mentioned, and whole sects, both among Catholics and Protes- 
tants, exhibited all the manifestations of the disorder. 

Most of the religious impostors who have at various times made 
their appearance, and many very sincere and devout persons, have been 
ecstatics. ' 

In its combinations with catalepsy, chorea, and hysteria, ecstasy has 
frequently played an important part in the history of the civilized world 
— at one time, leading to a belief in witchcraft ; at another, to demoni- 
ac and angelic possession ; at another, to mesmerism and clairvoyance; 
and, in our day, tc spiritualism. The consideration of these follies, 



ECSTASY. 753 

though interesting, scarcely comes within the scope of the present 
treatise. 

But within the last few years several very remarkable examples of 
ecstasy have been observed, and some references to two or three of 
them will probably not be out of place. 

First among them, as well on account of the interesting phenom- 
ena manifested as from the fact that the patient was regarded by a 
great many religious enthusiasts — physicians among them — as the sub- 
ject of miraculous interference, must be placed Louise Lateau. 1 With- 
out going into the full details of the case, a short account will probably 
prove both interesting and instructive : 

Louise Lateau was born at Bois-d'Haine, a small village in Belgium, 
on the 30th of January, 1850. She was reared in the utmost poverty, 
was chlorotic, and did not menstruate till she was eighteen years old. 
She loved solitude and silence, and when not engaged in work — and 
she does not appear to have labored much — she spent her time in medi- 
tation and prayer. She was subject to paroxysms of ecstasy, during 
which, as many other ecstatics, she spoke very edifying things, of char- 
ity, poverty, and the priesthood. She saw St. Ursula, St. Roch, St. 
Theresa, and the Holy Virgin. Persons who saw her in these states 
declared that, while lying on the bed, her whole body was raised up 
more than a foot high, the heels alone being in contact with the bed. 

The stigmatization ensued very soon after these seizures. On a Fri- 
day she bled from the left side of her chest. On the following Friday 
this flow was renewed, and in addition blood escaped from the dorsal 
surface of both feet ; and on the third Friday not only did she bleed 
from the side and feet, but also from the dorsal and palmar surfaces 
of both hands. Every succeeding Friday the blood flowed from these 
places, and finally other points of exit were established on the forehead 
and between the shoulders. 

1 For the theological view of this remarkable case the reader is referred to the follow- 
ing works, a part only of those written in support of her pretensions : " Louise Lateau de 
Bois-d'Haine, sa vie, ses extases, ses stigmates ; etude medicale," par le Dr. F. Lefebvre, 
professeur de pathologie generale et de therapeutique a la universite catholique de Lou- 
vain, etc., Louvain, 1873 ; " Les stigmatisees Louise Lateau de Bois-d'Haine, sceur Ber- 
nard de la Croix, etc.," par le Dr. A. Imbert-Gourbeire, professeur a l'ecole de medecine 
de Clermont Ferrand, Paris, 1873 ; " Biographie de Louise Lateau, la stigmatisee de Bois- 
d'Haine," par H. Van Looy-Tournai, Paris and Leipzig, 1874 ; " Louise Lateau la stigma- 
tisee de Bois-d'Haine d'apres des sources authentiques, medicales et theologiques," par 
le professeur docteur A. Rohling, translated from the German by Dr. Arsene de None, 
Bruxelles et Paris, 1874; "Louise Lateau, ihr Wunderleben und ihre Bedutung im 
deutscher Kirchenconflicte," von Paul Majuncke, Berlin, 1875. 

Among the treatises in which the miracle is denied, and the phenomena attributed to 
either disease or fraud, are : " Louise Lateau, Rapport medicale sur la stigmatisee do Bois- 
d'Haine fait a l'academie royale de medecine de Belgique," par le Docteur Warlomont, 
Bruxelles and Paris, 1875 ; "Science et miracle, Louise Lateau, ou la stigmatisee beige," 
par le Dr. Bourneville, Paris, 1875 "Les miracles," par M. Yirchow, Revue des cours 
scientifiques, January 23, 1875. 
49 



754 CEREBRO-SPINAL DISEASES. 

At first these bleedings only took place at night, but after two or 
three months they occurred in the daytime, and were accompanied by 
paroxysms of ecstasy, during which she was insensible to all external 
impressions, and acted the passion of Jesus and the crucifixion. 

M. Warlomont, being commissioned by the Royal Academy of Medi- 
cine of Belgium to examine Louise Lateau, went to her house, accom- 
panied by several friends, and made a careful examination of her per- 
son. At that time, Friday morning at six o'clock, the blood was flow- 
ing freely from all the stigmata. In a few moments the sacrament 
would be brought to her, and then the second act of the drama would 
begin. The scene that followed can be best described in M. Warlo- 
mont's own words : 

" It is a quarter-past six. ' Here comes the communion,' said M. 
Niels [a priest], ' kneel down.' Louise fell on her knees on the floor, 
closed her eyes and crossed her hands, on which the communion-cloth 
was extended. A priest, followed by several acolytes, entered ; the 
penitent put out her tongue, received the holy wafer, and then re- 
mained immovable in the attitude of prayer. 

" We observed her with more care than seemed to have been hith- 
erto given to her at similar periods. Some thought that she was simply 
in a state of meditation, from which she would emerge in the course of 
half an hour or so. But it was a mistake. Having taken the commun- 
ion, the penitent went into a special state. Her immobility was that 
of a statue, her eyes were closed ; on raising the eyelids the pupils 
were seen to be largely dilated, immovable, and apparently insensible 
to light. Strong pressure made upon the parts in the vicinity of the 
stigmata caused no sensation of pain, although a few moments before 
they were exquisitely tender. Pricking the skin gave no evidence of 
the slightest sensibility. A limb, on being raised, offered no resistance, 
and sank slowly back to its former position. Anaesthesia was complete, 
unless the cornea remained still impressionable. The pulse had fallen 
from 120 to 100 pulsations. At a given moment I raised one of the 
eyelids, and M. Verriest quickly touched the cornea. Louise at once 
seemed to recover herself from a sound sleep, arose and walked to a 
chair, upon which she seated herself. 'This time,' I said, 'we have 
wakened her.' ' No,' said M. Niels, looking at his watch, ' it was time 
for her to awake.' " 

She remained conscious ; the blood still continued to flow ; the an- 
aesthesia had ceased, her pulse rose to 120, and at the end of half an 
hour she was herself. " Our first visit ended here. At half -past eleven 
we made another. The poor child had resumed her attitude of extreme 
suffering, against which she contended with all the energy that re- 
mained to her. The wounds in the hands still continued to bleed. M. 
Verriest auscultated with care the lungs, heart, and great vessels, and 
found the bruit de souffle which he had detected in the morning at the 



ECSTASY. 755 

apex of the heart and over the carotids. The handle of a spoon piessed 
against the velum, the base of the tongue, and the pharynx, provoked 
no effort at vomiting. The glasses of our spectacles, as they came in 
contact with the air expired, were covered with vapor. As the patient 
appeared to suffer from our presence, we went away. 

" We made our third visit at two o'clock. There were still fifteen 
minutes before the beginning of the ecstatic crisis, which always took 
place punctually at a quarter-past two and ended at about half -past four. 
The pupils at this time were slightly contracted, the eyelids were 
almost entirely closed; the eyes, looking at nothing, were veiled from 
our view. We tried in vain to attract her attention ; her mind was 
otherwise engaged, and her pains were evidently becoming more in- 
tense. At exactly a quarter-past two her eyes became fixed in a direc- 
tion above and to the right. The ecstasy had begun. 

" The time had now come to introduce those who were prompted bj r 
curiosity. This could now be done without inconvenience, for the ec- 
static, for the ensuing two hours, would be lost to the appreciation of 
what might be passing around her. The room crowded could hold about 
ten persons, but enough were allowed to enter to make the total twenty- 
five. These placed themselves in two ranks, of which the front one 
kneeling allowed the rear one to see all that was going on. All this 
was done under the direction M. le Cure, who took every pains to give 
us a good view of what was going to happen. 

"Louise was seated on the edge of her chair; her body, inclined 
forward, seemed to wish to follow the direction of her eyes, which did 
not look, but were fixed on vacancy. Her eyes were opened to their 
fullest extent, of a dull, lustreless appearance, turned above and to the 
right, and of an absolute immobility. A few workings of the lids were 
now observed and became more frequent if the eyelids were touched. 
The pupils, largely dilated, showed very little sensibility to light, and 
all that remained of vision was shown by slight winking when the hand 
was suddenly brought close to the eyes. The whole face lacked ex- 
pression. At certain moments, either spontaneously or as a conse- 
quence of divers provocations, a light smile, to which the muscles of the 
face generally did not contribute, wandered over her lips. Then the 
face resumed its primitive expression, and thus she remained for the 
half -hour which constituted the ' first station.' 

" The c second station ' was that of genuflection. It had failed at 
one time, but had again appeared. The young girl fell on her knees, 
clasped her hands, and remained for about a quarter of an hour in the 
attitude of contemplation. Then she arose and again resumed her sit- 
ting posture. 

"The ' third station' began at three o'clock. Louise inclined her- 
self a little forward, raised her body slowly, and then extended herself 
at full length, face downward, on the floor. There was neither rigidity 



756 CEREBRO-SPINAL DISEASES. 

nor extreme precipitation ; nothing, in fact, calculated to produce in- 
juries. The knees first supported her body, then it rested on these and 
the elbows, and finally her face was brought in actual close contact with 
the tiled floor. At first the head rested on the left arm, but very soon 
the patient made a quick and sudden movement, and the arms were ex- 
tended from the body in the form of a cross. At the same time the feet 
were brought together so that the dorsum of the right was in contact 
with the sole of the left foot. This position did not vary for an hour 
and a half. When the end of the crisis approached the arms were 
brought close to the sides of the body, then suddenly the poor girl rose 
to her knees, her face turns to the wall, her cheeks become colored, 
her eyes have regained their expression, her countenance expands, and 
the ecstasy is at an end." 

Further particulars are given, and an apparatus was constructed 
and applied to Louise's hand and arm so as to prevent any external ex- 
citation of the haemorrhage. It was apparently shown that there was 
no such interference, for the blood began to flow at the usual time on 
Friday. 

In addition to the stigmata and the paroxysms of ecstasy, Louise 
declared that she did not sleep, had eaten or drunk nothing for four 
years, had had no fecal evacuation for three years and a half, and that 
the urine was entirely suppressed. 

M. Warlomont examined the blood and products of respiration 
chemically, and satisfied himself of their normal character, except that 
the former contained an excessive amount of white corpuscles. 

When being closely interrogated, Louise admitted that, though she 
did not sleep, she had short periods of forgetfulness at night. On M. 
Warlomont suddenly opening a cupboard in. her room, he found it to 
contain fruit and bread, and her chamber communicated directly with a 
yard at the back of the house. It was therefore perfectly possible for 
her to have slept, eaten, defecated, and urinated, without any one know- 
ing that she did so. 

The conclusions arrived at by M. Warlomont were, that the stigma- 
tisations and ecstasies of Louise Lateau were real and to be explained 
upon well-known physiological and pathological principles, that she 
' worked, and dispensed heat, that she lost every Friday a certain quan- 
tity of blood by the stigmata, that the air she expired contained the 
vapor of water and carbonic acid, that her weight had not materially 
altered since she had come under observation. She consumes carbon 
and it is not from her own body that she gets it. Where does she get 
it from ? Physiology answers, ' She eats.' " 

MM. Mauriac and Verdalle 1 give a very interesting account of an 
ecstatic woman who daily enacted the passion of Jesus, terminating in 
the usual manner with the representation of the crucifixion. This worn- 

1 "Etude mSdicale sur l'extatique de Fontet," Paris, 1875. 



ECSTASY. 757 

an, Beguille, was of nervous temperament, had had many visions of 
the Virgin and of angels, and was accustomed to prophesy. 

When visited by MM. Mauriac and Verdalle, Berguille was lying in 
bed. She is described as a woman of about forty-five years old, brown 
complexion, muscles and limbs well developed but without much fat, 
eyes blue, widely open, and staring vaguely. She smiled kindly when 
questions were put to her, and answered with sufficient intelligence. 

On being asked why she was in bed, she answered that she was in 
pain night and day ; and, when requested to state where she felt the 
most pain, she answered, the backs and palms of the hands, the tips 
and soles of the feet, and the right side. (It will be remembered that 
Louise Lateau had her pain and haemorrhage in the left side, a differ- 
ence which the miracle-believers ought to find it difficult to reconcile.) 

Relative to her visions and what she heard during her ecstasies, she 
said that she saw Jesus Christ in his passion, that she heard voices, but 
she could not repeat what was told her. Her pulse was from 68 to 72. 

At about one o'clock the ecstasy began. Her pulse rose to 80. 
She clasped her hands on her heart, her gaze became fixed, her eyes 
were widely opened, her lips moved as if she were murmuring prayers, 
and there were frequent movements of deglutition. Her pupils were 
slightly dilated, but contracted when a light was brought to them. 
Her limbs were rigid, but it was noticed that she flexed them very read- 
ily when she altered her position a little or arranged her dress. In a 
few minutes she raised herself somewhat awkwardly on her knees, her 
hands still being clasped and her eyes fixed. Then began the passion or 
the way to the cross, during which she walked on her knees around the 
bed, changing her position twelve times, and falling three times in the 
traditional manner. To make this journey required thirty-six minutes, 
and, this done, the next act, the crucifixion, was in order. 

Suddenly she threw herself back on the bed, extended her arms 
from each side, and remained immovable. The pulse was 112, the res- 
pirations 100. The muscles of the chest seemed to be paralyzed, only 
the diaphragm acting. The eyes were closed. 

The limbs were in a state of forced extension and very rigid ; the 
cutaneous sensibility to pinchings, prickings, and to the electrical 
stimulus was abolished. The latter, a very strong induced current, 
caused muscular contractions but no sensation. There was not the 
least flinching. Things went on in this way for over three hours, and 
then she sang the Salve Regina y exclaimed " Oh, what sorrow ! " and 
gradually recovered her senses. 

M. Bourne ville * cites the case of Ler., a hystero-epileptic, to whom 
reference will be again made, who at one time had a cruciform par- 
oxysm. Her head was strongly thrown back ; her eyelids, half open, 

1 "Louise Lateau," etc., Paris, 1875, p. 13. 



758 



CEREBRO-SPINAL DISEASES. 




ECSTASY. 759 

were in continual motion ; the muscles of the jaws were contracted, 
and the muscles of the neck were hard and tense. 

The superior extremities were extended at right angles from the 
trunk, the hands closed, and the fingers flexed so strongly on the palms 
as to render it impossible to open them. 

The inferior extremities were stretched out to their full length, the 
sole of one foot in contact with the dorsum of the other. 

In a word, the rigidity was such that the body could have been 
raised from either end like a bar of iron (Fig. 107). 

The attack lasted about four hours ; then Ler. opened her eyes and 
recovered consciousness, exclaiming, " O my God, I was so happy ! " 

Two other interesting cases are described by M. Billet, 1 but the fore- 
going are sufficient to give the reader some idea of ecstasy as it ap- 
pears in Catholic countries. 

But the phenomena exhibited by Protestant ecstatics have been 
and are to this day fully as remarkable pathologically as those just de- 
scribed. Calmeil, 2 speaking of the Protestant theomaniacs of Langue- 
doc and Cevennes, says : 

" In general, they gave the name of ecstatic period to the agitation 
and improvisation which characterized the attack. All the inspired 
were fully persuaded thai the Holy Spirit had entered into their breasts 
at the moment when they felt themselves constrained by an overwhelm- 
ing power to prophesy. All expressed themselves as if the Spirit of 
God spoke to them the words they uttered." 

Elizabeth Barton, called the " Holy Woman of Kent," announced, 
during an attack of hysteria, that a child then sick with a brain- 
fever would die. As she predicted, the event took place soon after- 
ward, and the fulfillment of this prophecy at once gave the holy woman 
a great reputation. On this she announced that she was illumined by 
the Holy Spirit. She had numerous ecstatic paroxysms, during which 
she, according to her own account, was transported to heaven, and on 
her emergence she sang hymns, prayed, and made many predictions 
which astonished her admirers. At last, in obedience to an asserted 
command of the Virgin, she renounced Protestantism and took the veil. 
She continued to prophesy, and, growing bold, she predicted the speedy 
death of the king for his putting aside his wife Catharine of Aragon 
for Anne Boleyn. Henry VIII. was not of the temper to submit to 
this sort of holiness, so he had Elizabeth Barton beheaded as a pesti- 
lent woman, who was better out of the world than in it. 

An ecstatic, in a paroxysm of rapture, having lost his speech, thus 
describes his regaining the faculty : 3 

"At length, after nine months of sobs and convulsions without 

1 " Contributions a l'etude des nevroses extraordinaires," Paris, 18H. 

2 " De la folie," etc., tome h\, Paris, 1845, p. 288. 

3 Calmeil, op. cit., p. 289. 



760 CEREBRO-SPINAL DISEASES. 

speech, one Sunday morning as I was praying in my father's house, I 
fell into an extraordinary ecstasy, and God opened my mouth. During 
the ensuing three days I was constantly under the operation of the 
Holy Spirit, neither eating, drinking, nor sleeping, and I spoke often 
with more or less power, according to the nature of things. All in the 
family were convinced, as well by the extraordinary state in which they 
now saw me, as by the wonderful fasting of three days, during which I 
felt neither hunger nor thirst, that it was surely by the Sovereign 
Power that such astonishing things were done." 

In our own day, instances of ecstatic trance during camp-meetings, 
revivals, and the like, are common enough, and the number is greatly 
jicreased by spiritualism, mesmerism, and such like absurdities. 1 

As we have seen, many ecstatics pretend that they do not eat. 
Cases of the kind are reported very often, and have been noticed from 
an early period. Thus Schenckius a quotes from Paulus Lentulus tho 
"Wonderful History of the Fasting of Appolonia Schreira, a Virgin, 
in Bern," in which it is stated that, being carefully watched by the 
orders of the magistrates of Bern, it was ascertained that there was no 
fraud, and she was dismissed as a genuine case of ability to live with- 
out food. During the first year of her fasting she scarcely slept, and 
in the second year not at all. • 

Another, and still earlier case, was that of Margaret Weiss, aged ten 
years, who lived in Rode, a small village near Spires, and whose history 
is given by Gerardus Bucoldianus. 3 Margaret is reported to have ab- 
stained from all food and drink for three years, in the mean time grow- 
ing, walking about, laughing and talking, like other children of her age. 
She, however, during the first year suffered greatly from pains in her 
head and abdomen, and, all four of her limbs were contracted. She 
passed neither urine nor faeces. Margaret played her part so well that, 
after being watched by the priest of the parish, and Dr. Bucoldianus, 
she was considered free from all juggling, and was sent home to her 
friends by order of the king, "not without great admiration and 
princely gifts." The circumstances seem to have somewhat stag- 
gered Dr. Bucoldianus, for he asks, "Whence comes the animal heat, 
since she neither eats nor drinks, and why does the body grow when 
nothing goes into it ? " 

Of the cases that have been recently reported, that of the so-called 
Welsh fasting-girl 4 is one of the most remarkable, and a few years ago 
an account of its tragical ending excited a good deal of comment in the 

1 For a full discussion of this subject, the reader is referred to the author's work 
" On Certain Conditions of Nervous Derangement," New York, 1881. 

2 " HapaT7)p?]ceov, sive observationum medicarum, rararum, novarum, admirabilium et 
monstrosarum volumen, tomis septeni de toto homine institutum," Lugduni, 1606, p. 306. 

3 " De Puella quae sine cibo et potu vitam transigit," Parisiis, ann. MDXLII. 

4 " A Complete History of the Welsh Fasting Girl, with Comments thereon, and Obser- 
vations on Death from Starvation," by Robert Fowler, London, 1871. ■ 



ECSTASY. 761 

medical journals of Great Britain. Like the others, this was a case of 
hysteroid disease, and when she was so strictly watched that deception 
was no longer possible, she died in a few days of starvation. The 
startling* heading to an editorial notice in the Lancet 1 — " Starved to 
Death " — expressed no more than the actual truth. 

In regard to the rarity of defecation and urination in cases of hys- 
teroid disease there is no doubt. Such cases are often accompanied 
with vomiting, and then the matter ejected from the stomach contains 
urea and sometimes even fecal matter. A lady, not long since under 
my charge, in whom there were no other very decided hysterical symp- 
toms, had an operation from her bowels never more frequently than 
once a month, and generally not so often. Every time she ate any- 
thing she vomited soon afterward, and the vomited matter always con- 
tained urea. She urinated about a tablespoonful every eight or ten 
days. The vomiting of fecal matter in cases of hysteroid disease is not 
so common. Briquet a reports a case as occurring in his own experi- 
ence, in which there was no doubt that substances administered as 
enemas were vomited a few minutes afterward. Among other experi- 
ments, and in order to remove all doubt arising from the use of house- 
hold substances, an injection of tincture of litmus was given immedi- 
ately after it was brought from the pharmacy. The patient was told 
that coffee was to be injected. Twelve minutes afterward the tincture 
of litmus was vomited, its blue color turned to a red through the action 
of the gastric juice. 

Less authentic, perhaps, is the following from Henricus ab Heeres: 3 

" A certain gentleman has lived several years without having had 
any operation from his bowels. About the middle of the day he sits 
down to his dinner, usually inviting several noble persons to eat with 
him. In an hour he rises from the table, after having eaten and drunk 
to his satisfaction, and retiring, vomits the dinner he had eaten the day 
before, but retaining all the dinner he has just taken. It is ejected 
putrid and filthy, differing in no respect from other excrement. He 
vomits with ease, and at once, throwing up the contents of the stomach 
which have remained from the previous day. Then he washes his 
mouth with clean water and returns to his friends to finish his repast. 
He eats no supper or breakfast, and thus he has done for about twenty 
years." 

Stigmata, as occasional symptoms of the hysteroid condition, are 
well known to dermatologists, many cases of bloody sweat having been 
noticed. Those observed in the case of Louise Lateau were well studied 
by M. Worlomont, and they were found to differ in no essential respect 
from those previously observed, except in regard to the periodicity of 

1 Lancet, December 25, 1869. 

2 " Traite clinique et therapeutique de Thysterie," Paris, 1859, p. 316. 
8 " Observationes medicae," Lipsige, 1645, lib. 1, ob. 29. 



762 CEREBRO-SPINAL DISEASES. 

the haemorrhages — a circumstance, however, easily accounted for by 
the fact that the stages of excitement were regular. Hsemidosis, or 
bloody sweat, is to be regarded as one of the neuroses of the skin. An 
interesting case is reported by Wilson. 1 Mason Good cites authorities to 
show that it has taken place during coition, violent terror, and great 
bodily agony. Its occurrence in the hands, feet, and side, is to be ex- 
plained by the fact that the attention is strongly concentrated on these 
parts, and it is in all probability kept in these situations by manual 
irritation. It is by no means certain that this latter was not the case 
with Louise Lateau, for M. Warlomont's apparatus was not of such a 
character as to prevent such action. 

Causes. — Ecstasy, though not entirely confined to the female sex, is 
very much more common in women than in men. It appears to be 
produced in those who are of delicate and sensitive nervous organiza- 
tions by intense mental concentration on some one particular subject — 
generally, one connected with religion, or some other abstract train of 
thought. It was formerly quite common among the inmates of con- 
vents, and is now not unfrequently met with at camp-meetings and 
spiritualistic gatherings. 

There are no points about the Diagnosis requiring special considera- 
tion, and the Prognosis is always favorable, if the subject can be sub- 
mitted to proper moral and physical treatment. As the disease is 
never fatal per se, we know nothing of its Morbid Anatomy. The 
pathology, as indicated by the symptoms, points to the implication of 
both the brain and spinal cord, but there is no satisfactory theory of 
the disorder other than that which refers it to cerebral and spinal pre- 
occupation — a kind of setting of the current in one direction, whereby 
all other occupation is for the time prevented. 

Treatment. — The means of treatment, though not differing essen- 
tially from those proper for catalepsy, require, nevertheless, special 
mention of some particulars. The influence of moral force in prevent- 
ing and curing ecstasy is well marked, and many instances are on record 
in which epidemics of it have been arrested by arguments addressed to 
the fears of the subjects. I have several times aborted and prevented 
ecstatic manifestations by making preparations to cauterize the region 
of the spine with a red-hot iron. 

A great deal can be done by giving as little notoriety to ecstatics 
as possible. They glory in the idea that they are of sufficient impor- 
tance to excite attention and discussion, and they are accordingly 
stimulated to continue their performances so long as they are noticed 
and an air of mystery is attached to them. 

Removal from all associations calculated to continue the exciting 
and morbid train of thought which has developed the disease under 
notice, should, of course, be a point in the treatment. 

1 "On Diseases of the Skin," American edition, Philadelphia 1863, p. 551. 



HYSTERO-EPILEPSY. 763 

Electricity, and the other measures of treatment recommended foi 
catalepsy, will prove serviceable in ecstasy. By galvanization of the 
sympathetic nerve, I, on one occasion, immediately cut short a parox- 
ysm of ecstasy, and, by continuing the practice every alternate day for 
about six weeks, effectually cured the patient, who for several years 
had been subject to seizures every two or three days. 

As means for improving the general health are almost invariably 
required, iron, quinine, and strychnia, in the combination recommended 
on page 54, may be administered with advantage. I have great confi- 
dence in the bromides, and the patient should be to a moderate extent 
brought as soon as possible under the influence of some one of those 
previously mentioned. 

III. 

HYSTERO-EPILEPSY. 

The combination of hysteria with epilepsy has long been recognized 
as existing and as giving rise to one of the most frightful affections to 
be found in the whole range of neurological medicine. In the present 
state of our knowledge it would, perhaps, be going too far were we to 
pronounce positively in favor of its being a distinct pathological entity 
with a different anatomical substratum from either hysteria or epilepsy, 
and yet the phenomena are so distinct that we certainly are warranted 
in considering it separately from either of these diseases. 

Symptoms. — An attack of hystero-epilepsy is characterized by the 
occurrence of convulsions more or less resembling those of epilepsy. 
There is usually in the first place a well-marked tetaniform spasm, 
though, sometimes, this is not very decided, and occasionally is not 
observed at all. Then follow clonic convulsions, during which the 
patient froths at the mouth and may pass the urine or bite the tongue, 
though these phenomena, especially the latter, are rare. Loss of con- 
sciousness exists during this stage. 

Next ensues a remarkable series of movements, at the beginning of 
which, or during their continuance, the patient recovers consciousness 
to such an extent as to answer questions, although there is no after- 
recollection of the incidents that may have occurred. These move- 
ments are apparently voluntary, and consist of the most extraordinary 
contortions of the muscles of the face, neck, trunk, and extremities, so 
that superstitious people might well imagine the existence of an inter- 
nal or external diabolical agency. During the continuance of this part 
of the paroxysm the patient tears with the hands and teeth any thing 
tearable that comes within reach, and continually utters inarticulate 
sounds or words apparently in relation with the ideas passing through 
the mind. Finally, the purely hysterical element ceases to predomi- 
nate, and the patient alternately weeps and laughs, and gradually ac- 
quires a knowledge of what is passing around. 



764 



CEREBRO-SPINAL DISEASES. 



During the whole of the paroxysm the face is flushed, the pupils are 
moderately contracted, the pulse is accelerated, the perspiration is in- 
creased in quantity, and the respiration is hurried and irregular. 

But there are numerous deviations from this type of a seizure. 
Sometimes the tetanic spasm is wanting, and again it, or some modifi- 
cation of it, may constitute the most marked part of the convulsive 
period. Thus in a lady, who was lately under my charge, the paroxysm 
began with an opisthotonos, which was immediately relaxed, and again 
renewed, to be again relaxed, and so on, for over half an hour. 

In a woman whom I saw in the Pennsylvania Hospital several years 
ago, in the service of Dr. Pepper, the convulsions consisted of a series 
of rapid movements produced, as the patient lay on her bed, by the 
bending back of the body, so as to throw it into an opisthotonotic posi- 
tion, the head and heels alone touching the bed, and then, the muscles 
being suddenly relaxed, allowing the buttocks to fall with force on the 
bed. These actions were continued with great rapidity, and without 
intermission for an hour or more, and were succeeded by a period dur- 
ing which there were alternate laughing and weeping. 

Such cases are what Sauvages designated as hysteria libidinosa. 

But, in a case now under my care, the patient, a woman, has daily 
attacks at about the same hour — three o'clock p. m. — which are more dis- 
tinctly tetaniform in the beginning than any that have come under my 
observation. They consist of a series of opisthotonotic spasms, during 
which the body is extremely rigid. The convulsion is, however, unlike 
the others referred to, very slowly developed. The body extended at 
full length in the recumbent posture gradually becomes rigid, the legs 
are slightly abducted, the arms are pressed strongly against the sides, 

Fig. 108. 




the jaws are tightly closed, and the gaze fixed (Fig. 108). Respiration 
is entirely suspended, and the heart beats rapidly, sometimes as fre- 
quently as one hundred and sixty per minute. Then the body is slowly 
bowed, so that the head and heels alone touch the bed, and is so rigid 
and strongly arched that no ordinary force, such as a powerful man 
can exert, suffices to overcome the tonicity of the muscles. In about a 
minute from the beginning of the rigidity, the spasm suddenly relaxes, 
and with a long-drawn inspiration the paroxysm ends — to be again re- 



IIYSTERO-EPILEPSY. 



765 



sumed in a few minutes with a like sequence. In the accompanying 
woodcut (Fig. 109) is an exact representation of this patient when the 
tetanic spasm is at its height. 




In this case there is a distinct aura starting from the left ovary, and 
strong pressure exerted upon this organ suffices generally, though not 
always, to cut short the series of paroxysms. 

Under the name of demonomania many cases of hystero-epilepsy 
have been described, and the disease, like chorea, has at times prevailed 
epidemically. At Loudun, in France, it led to the death at the stake 
of Urbain Grandier, the nuns, who were its subjects, accusing him in 
their delirium of having bewitched them. At Marseilles, Father Louis 
Gaufridi, a man of education and of strict morality, was accused by two 
Ursuline nuns of having debauched them through diabolical agency. 
At the time of the accusation, these nuns, one of them only nineteen 
years old, were suffering from attacks characterized by hallucinations 
and illusions, fearful epileptiform and cataleptiform convulsions, and 
delirious ravings — all of which were ascribed to the devil moved and in- 
stigated by Louis Gaufridi. At first, the accused denied the charges 
made against him, and endeavored by arguments to show the real 
nature of the seizures. But the effort was in vain, just as is the at- 
tempt now to convince the credulous and ignorant of the real nature 
of the seizures of Louise Lateau, Bernadette Soubirous — who evoked 
Our Lady of Lourdes — and of the hundreds of mediums, ecstatics, and 
hysterics, who pervade the world. Gaufridi became insane, and con- 
fessed all that was laid to his charge, with numerous other offenses 
which had not been imagined. He declared that he had worshiped the 
devil for fourteen years ; that the demon had given him power to render 
amorous of his person all women on whom he should breathe, and that 
he had thus overcome several thousand women! Gaufridi, after horrible 
tortures, was burned at the stake ; and the two nuns " continued to be 
delirious," as well they might. 

As showing the nature of the phenomena exhibited in cases of de- 



766 CEREBRO-SPIXAL DISEASES. 

moniacal possession and their resemblance to the symptoms of hystero- 
epilepsy and other forms of hysteria, I subjoin the following questions 
as proposed by Santerre, priest and promoter of the diocese of Nimes, 
to the University of Montpellier : 

Question 1. Whether the bending, moving, and removing of the 
body, the head touching sometimes the soles of the feet (opisthotonos), 
and other contortions and strange postures, are a good sign of posses- 
sion? 

2. Whether the quickness of the motion of the head forward and 
backward, bringing it to the back and breast, be an infallible mark of 
possession ? 

3. Whether a sudden swelling of the tongue, the throat, and the 
face, and the sudden alteration of the color, are certain marks of pos- 
session ? 

4. Whether dullness and senselessness or the privation of sense, even 
to be pinched and pricked without complaining, without stirring, and 
even without changing color, are certain marks of possession ? 

5. Whether the immobility of all the body, which happens to the 
pretended possessed by the command of their exorcists, during and in 
the middle of the strongest agitations, is a certain sign of a truly dia- 
bolical possession ? 

6. Whether the yelping or barking like that of a dog, in the breast 
rather than in the throat, is a mark of possession ? 

7. Whether a fixed, steady look upon some object, without moving 
the eye on either side, be a good mark of possession ? 

8. Whether the answers that the pretended possessed make in 
French to some questions that are put to them in Latin are a good 
mark of possession. 

9. Whether to vomit such things as people have swallowed be a sign 
of possession ? 

10. Whether the prickings of a lancet upon divers parts of the body 
without blood issuing therefrom are a certain mark of possession ? 

All these questions, to the credit of medical science — which has 
always, notwithstanding the weakness of some of its professors even in 
our own day, been steadily opposed to supernaturalism— were answered 
in the negative. No one can read them without being struck with the 
facts that Father Santerre was at least a good symptomatologist, and 
of the absolute identity of the phenomena cited, in all essential char- 
acteristics, with those which in our day are said to be of mystical origin, 
but which in reality are hysterical or hysteroid. We might reproach 
Father Santerre and his coadjutors more forcibly, if we had not our- 
selves killed witches and presided at the birth of spiritualism. 

No one has written with greater effect in regard to the manifesta- 
tions of hysteria and hystero-epilepsy than Charcot. As a most strik 



HYSTERO-EPILEPSY. 



767 



ing case of the latter affection, I cite from him the following instance 1 
already referred to in another connection under the head of ecstasy. 

Ler., aged forty-eight years, is a patient well known to all physi- 
cians who visit the Salpetriere as one of the most remarkable instances 
extant of hystero-epilepsy. Her menstruation has ceased for four 
years and yet all the neurotic symptoms persist. She is a demoniac, a 

Fig. 110. 




possessed, and presents a striking example of that type of hysteria 
manifested by the " Jerkers " in " Methodist camp-meetings," and who 
exhibit in their paroxysms the most frightful attitudes. 

The probable origin of these nervous phenomena in Ler. deserves to 
be noted. She has had, as she says, a series of frights. At eleven 
years of age she was terrified by a furious dog. At sixteen she was 

1 "Le9ons sur les maladies du sjsteme nerveux faites a la Salpetriere," Paris, 18V2-'Y3, 
p. 301, el seq. 



'68 



CEREBRO-SFINAL DISEASES. 



frightened at the sight of the corpse of an assassinated woman, and 
again about the same time, when going through a wood, by robbers who 
attacked her and took her money. 

With her there are local hysterical manifestations consisting of 
hemi-anaesthesia, ovarian tenderness, paresis, and at times contraction 
of the limbs on the right side. Sometimes these symptoms are shown 
on the left side also. 

The attacks, which are announced by a well-marked ovarian aura, 
are characterized at first by epileptiform and tetaniform convulsions ; 

Fig. 111. 




after which come extensive movements of an intentional character, m 
which the patient assumes the most hideous postures, recalling the 
attitudes which history ascribes to demoniacal possession (Figs. 110 and 
111). At the moment of the attack she is seized with delirium, which 
evidently turns on the events which have produced the initial seizures, 



HYSTERO-EPILErSY. 



769 



She hurls invectives at imaginary persons. " Scoundrels ! robbers! brig- 
ands. Fire, fire ! Oh, the dogs, they bite me ! " 

When the convulsive part of the accession is over, there ensue, gen- 
erally, hallucinations of sight — she sees frightful animals, skeletons, 
and spectres ; a paralysis of the bladder ; a paralysis of the pharynx; 
and a contraction, more or less permanent, of the tongue. 

It is therefore necessary for several days to feed her through a tube, 
and to empty the bladder with a catheter. 

Later, M. Bourneville ' has given an account of Ler., somewhat 
fuller than that of M. Charcot, to which, as showing how Ler. had at 
one time exhibited phenomena of ecstasy similar to those present in 
Louise Lateau, reference has already been made. In further illustra- 
tion of the period of contortions in her case I take from M. Bourneville's 
excellent monograph the accompanying woodcut (Fig. 112), made from 
a sketch taken on the spot by M. Charcot. 

Fig. 112. 




In the intervals between the paroxysms the subjects of hystero-epi- 
lepsy generally exhibit some of the phenomena of hysteria such as hemi- 
ansesthetic contractions, ovarian tenderness, paralyses, etc. 

Eelative to the Causes, the Prognosis, Diagnosis, Morbid Anatomy 
and Pathology, and Treatment, there is nothing to add to the remarks 
already made when hysteria, catalepsy, and ecstasy, were under con- 
sideration. 

stigmatisee beige," Paris, 1875, p. 38, el seg. 



1 " Louise Lateau, 
50 



770 CEREBRO-SPINAL DISEASES. 

CHAPTER VII. 

MULTIPLE CEREBROSPINAL SCLEROSIS. 

We have already considered the subject of sclerosis as it affects the 
brain and spinal cord separately. We have still to treat of it as exist- 
ing in these nervous centres simultaneously. Although recognized, 
over thirty-five years ago, by Cruveilhier and Carswell, it is only re- 
cently, mainly through the observations of Charcot and Vulpian, that 
attention has been again directed to sclerosis of the cerebro-spinal 
variety, a form which differs from those already described in this 
treatise, both in its extent and in the symptoms by which it is charac- 
terized., 

Symptoms. — The initial symptoms vary according as the morbid 
process begins in the brain or spinal cord. In the former case, the first 
prominent manifestation of disease may be an epileptic fit. In other 
cases, there are headache, vertigo, ocular troubles, such as ptosis, diplo- 
pia, or amblyopia, failure of the hearing, and, very often, defective 
articulation. The mind does not participate to any considerable extent, 
unless the hemispheres be involved in the lesion. 

Or, there may be hemiplegia as a consequence of cerebral conges- 
tion, and even mania, from a like cause. These attacks are sometimes 
frequent, and usually leave more or less mental weakness after them. 

Tremor is often first seen in the tongue, more frequently in the eye- 
ball, of cnt or both sides, which oscillates when the patient is told to 
turn it inward »^r outward, but which is steady when he looks directly 
to the front. This tremor is called nystagmus, and is, as we have 
already seen, mot with in other diseases of the nervous system. Ac- 
cording to Feiriei's 1 observations, it is due to lesion of the cerebel- 
lum, and when met with in the disease under notice points to this organ 
as one of the seats of the morbid process. In the case of a woman who 
attended my clinic at the Bellevue Hospital Medical College, nystag- 
mus was the only symptom observed for over a year, and then gradu- 
ally other phenomena of the cerebro-spinal form of sclerosis made their 
appearance. 

Tremor is indicative of loss of power, and it gradually becomes more 
strongly marked and extends to other muscles of the body as other 
parts of the cerebro-spinal system become involved. It is never, how- 
ever, a constant phenomenon in any form of sclerosis affecting the 
spinal cord alone. Its presence is peculiar either to cerebral disease or 
to lesions occurring in the pons or in the medulla. 

After a time, which is subject to great variation in different cases, 

1 "Experimental Researches in Cerebral Physiology and Pathology," " West Riding 
Lunatic Asylum Medical Reports," vol. iii., 1873, p. 69. 



MULTIPLE CEREBRO-SPIXAL SCLEROSIS. 771 

the loss of power extends to the limbs, and this feature is often 
accompanied with aberrations of sensibility. If, as is generally 
the case, the membranes of the cord are congested or inflamed, 
there are spasmodic jerkings or twitchings of the limbs, but in some 
cases these are never observed. In the case of a gentleman from 
South Carolina, who consulted me at the instance of my friend 
and colleague Prof. J. T. Darby, and who was obviously affected 
with multiple cerebro-spinal sclerosis, there had never been the 
slightest involuntary movement, independent of the peculiar form 
of tremor in the limbs which constitutes so prominent a feature of 
the disease. 

The lower extremities are generally very much more paralyzed 
than the upper, and, when they become involved, festination often 
makes its appearance. The gait of the patient thus becomes similar 
to that of a person suffering from paralysis agitans. 

If the sclerosis begins in the brain before attacking the spinal 
cord, tremor precedes the paralysis — the affection being then en- 
tirely cerebral in character ; but when, as is generally the case, the 
lesion appears primarily in the spinal cord, paralysis is noticed be- 
fore the tremor. • In fact, there is never, as previously insisted on 
in my remarks on paralysis agitans, any tremor, unless the superior 
ganglia of the cerebro-spinal system are involved. The fact that it 
is only shown when a voluntary movement is made also assists us 
to distinguish it from the tremor of paralysis agitans, as well as from 
other forms of tremor. In the cerebro-spinal form of the disease, 
therefore, the patient remains without tremor so long as he is qui- 
escent. But if he attempts to cross one leg over the other, or to 
carry a glass of water to his lips, the extremity executing the move- 
ment is at once seized with tremor, and the act is performed with 
great difficulty. 

The ability to place the fingers on any part of the body, unassisted 
by the eyesight, is impaired, as in paralysis agitans, and in sclerosis 
affecting the posterior columns of the spinal cord. 

As the disease advances, symptoms indicative of lesions of the 
cord appear. These symptoms seldom point to disease of symmet- 
rical tracts. Thus, in one leg, the symptoms observed may be those 
of inflammation of the lateral pyramidal tract — that is, slight paresis, 
stiffness and rigidity of the muscles, exaggerated knee-jerk, and the 
ankle clonus, while the other leg may evince no abnormal symptoms 
whatever, or else may show evidence of disease of the posterior col- 
umns of the same side by the presence of pain, anaesthesia, loss of the 
knee-jerk, loss of the muscular sense, tactile sense, and temperature 
sense. The arms may show the same divergence of symptoms. There 
may also be paralysis of the bladder, constipation, and a tendency to 
the formation of bed-sores. 



772 CEREBRO-SPINAL DISEASES. 

Thus, it is evident that, in the affection under consideration, we 
are not confronted, as a rule, with lesions confined to one or more of 
the " system tracts." On the contrary, it is quite apparent that the 
diseased areas are scattered about in patches or islets, at one level 
affecting one tract, at another level another tract, while at many other 
levels the entire segment of the cord may be normal. The head symp- 
toms likewise increase in intensity, but the mind remains clear to the 
last in the great majority of cases. Indeed, my observation of many 
cases has convinced me that in the cerebro-spinal form of sclerosis the 
hemispheres are not often involved, even when the disease has lasted 
several years. 

The difficulties of articulation notably increase, and the muscles of 
deglutition likewise become involved. In consequence, the saliva is 
not swallowed as often as it should be, and it therefore dribbles from 
the mouth. Mastication is difficult, and the facial muscles gradually 
become involved. The countenance of the patient at this period is 
not unlike that of a person suffering from glosso-labio-laryngeal paral- 
vsis, as in fact might be expected, the same nerves and muscles being 
involved. Finally, the patient dies from exhaustion, or from some in- 
tercurrent disease. 

Few diseases are so irregular and ununiform in their phenomena as 
the cerebro-spinal form of sclerosis. This is due to the fact that the 
organs liable to be the seat of the disease are numerous and of varied 
functions. The essential feature of the affection is tremor occurring 
generally after paralysis, and only manifested during the performance 
of voluntary movements. It is not always necessary, however, that 
the movements should be of the partially -paralyzed limbs, for I have 
seen cases in which tremor was excited in a paretic leg by the act of 
executing voluntary movements with a sound hand. 

The following histories will contribute to a fuller understanding of 
the subject : 

Cruveilhier 1 reports the case of a cook, aged thirty-seven, who six 
years before coming under observation noticed that he was losing power 
in the left leg, so that he nearly fell in the street. Three months sub- 
sequently the right leg became similarly affected, and then the superior 
extremities followed. They were tremulous and weak, but the patient 
was still able to use them to some extent. The sensibility remained 
intact, and the reflex faculty of the cord was unimpaired. In other 
respects the patient was condemned to immobility. There were no 
spasmodic retractions of the limbs, and no painful contractions. The 
articulation was imperfect, but the intelligence was unaffected. There 
appear to have been no marked head-symptoms in this case. " Point 
de cephalalgie, jamais de cephalalgie, le malade entendait a merveille." 

1 " Anatomie pathologique du corps humain," Paris, 1835, 1812, tome ii., Ii7. xxxiL, 
Ffe. 4, PI. 2. 



MULTIPLE CEREBROSPINAL SCLEROSIS. 773 

After death there was found gray degeneration of the spinal cord, of 
the medulla oblongata, of the pons Varolii, of the right cerebral pedun- 
cle, of the right optic thalamus, of the corpora callosa, and of the for- 
nix. The hemispheres were not involved. 

Two other cases, similar in general character to the foregoing, are 
given, in neither of which were the hemispheres involved. 

Another case, that of Josephine Pajet, is cited by Cruveilhier. 1 In 
this there was almost complete insensibility of the inferior extremi- 
ties, though the patient was able to move the toes, the feet, and the 
legs. There were no cramps and no contractions. There was also 
diminished sensibility of the superior extremities. All the limbs 
were weak, and the arms were affected with tremor. The patient 
could walk and sew when first seen. The right hand was stronger 
than the left. There was a sensation of a tight band around the 
abdomen. After death there w T as gray degeneration of the cord, and 
of the pons Varolii. 

In none of these cases were there spasmodic jerkings or tonic con- 
tractions of the limbs. Two cases have been reported by Friedreich. 2 
In one of these a man, aged twenty-one, was the subject. Among the 
first symptoms were mental excitement, vertigo, pain in the head, and 
weakness of the lower extremities. The gait was unsteady, and there 
was tremor upon any emotional excitement, or on the attempt to exe- 
cute movements. This affected the upper and lower extremities, the 
head, and the eyeballs. After death, patches of sclerosed tissue were 
found on the tubercula mammillaria, the cerebral peduncles, the pons 
Varolii, and the medulla oblongata. 

The other case was that of a woman, aged twenty, who was attacked, 
when seventeen years of age, with weakness of the right leg. Soon 
afterward the left became affected, and subsequently the arms. These 
latter were rendered tremulous at every attempt to move them. The ■ 
speech was implicated, and there was nystagmus. The mind was weak- 
ened, and the sensibility was impaired. 

In the first of these cases the disease appears to have begun in the 
brain ; in the second in the spinal cord. 

Vulpian, 3 under a title which goes to show how even the best au- 
thorities have confused the whole subject of sclerosis, describes an in- 
teresting case communicated by Charcot. In this instance a woman, 
aged forty-three, of nervous temperament, had been subject to frequent 
attacks of facial neuralgia, and had often suffered from vague pains 

1 Op. cit., liv. xxxviii., Fig. 1, PI. 5. 

2 " Deutsche Klinik," No. 14, 1S56. 

3 " Note sur la sclerose en plaques de la moelle epiniere," V Union Medical', No. 
70, Juin 14, 1866, p. 507. Like other writers, Vulpian, in this paper, brings together 
cases which have no affinity except as regards the general character of the lesion. 



774 CEREBRO-SPINAL DISEASES. 

without determinate seat. In 1856, she suffered from attacks of ver- 
tigo, which, from being rare at first, subsequently came on five or six 
times a day. Sometimes she fell, but never lost consciousness, or had 
any convulsive movement. 

Shortly afterward, during the night, she was seized with vomiting, 
cramps in her limbs, and a numbness of the right side. In the morn- 
ing she was hemiplegic. Fifteen days afterward motion reappeared 
in the arm, but the leg remained paralyzed. In 1859, she had anoth- 
er attack of hemiplegia, and this time was deprived of speech for 
fifteen days. After this seizure, there were contractions of the flexors 
of the fingers, and of the forearm of the right side. In 1861, she had 
a third attack. 

In 1862 (January 1st) she came under M. Charcot's care. 

The intellectual faculties were not involved. The right superior 
extremity was almost entirely paralyzed, and was in a state of rigidity 
and contraction. The lower extremities were permanently extended, 
and could not be flexed but by great effort. Sensibility was perfect 
throughout, and reflex movements could still be excited. She died 
February 9th. 

On post-mortem examination, patches of sclerosed tissue were found 
in the right middle cerebral peduncle, the pons Varolii, the medulla ob- 
longata, and the cervical region of the spinal cord. The hemispheres 
were perfectly healthy. 

In this case, it is probable that the contractions were mainly due to 
secondary degeneration of the cord, a condition which, as we have seen, 
is analogous to sclerosis. It will be observed that there were no tre- 
mors, either with or without voluntary motions. 

Another important case has been reported by M. Magnan : 1 

A woman, aged thirty-four, came under observation. In 1848, 
when thirteen years of age, she had an attack of typhoid fever, from 
which she lost her sight. The first symptom of her disease occurred 
in 1867, and consisted of trembling of the hands and arms whenever 
she endeavored to execute any difficult movement. Before long, the 
tremor involved the lower extremities ; but there was no paralysis 
till about eight months previous to her admission to the hospital. At 
this time, every effort at motion caused tremor. The hands, arms, 
legs, eyeballs, and even the muscles of the trunk, were involved. The 
articulation was defective, and there were various painful sensations 
in different parts of the body. Ophthalmoscopic examination showed 
atrophy of the optic disks and nerves. 

The diagnosis in this case was multiple cerebro-spinal sclerosis — 
an opinion which I do not think is warranted by the facts. The lesion 
was probably entirely confined to the brain. The main reason which 

'* Hl Memoires de la societe de biologie," Paris, 1869. 



MULTIPLE CEREBRO-SPINAL SCLEROSIS. 775 

leads me to entertain this view is, that the tremor appeared before the 
paralysis. 

I cite the case for the purpose of showing how little accord there 
is among authors relative to the association of symptoms with lesions 
in the several forms of sclerosis. 

Thirty-one cases of what the symptoms indicated to be the cerebro- 
spinal form of sclerosis have been under my care ; and, though I 
have not had the opportunity of verifying my diagnosis in a single 
instance, I think the symptoms have been of such a character as to 
indicate the existence of the lesion so graphically described by Char- 
cot, Friedreich, and Bourneville and Guerard. 1 The fact, that sev- 
eral of the histories were written out before Charcot's investigations 
gave me a clew to their real import, will tend, I think, to increase 
their value. 

Mr. M., a gentleman fifty-three years of age, consulted me, at 
the instance of my friend Prof. Fordyce Barker, M. D., for partial 
paralysis with tremor, mainly affecting the right arm and leg. 
Two years previously he had suffered from vertigo and headache, 
which were followed by a slight attack of hemiplegia of the right 
side, unattended by loss of consciousness. He gradually recovered 
from this, but, about six months before he came under my observa- 
tion, he noticed that his right leg began to drag, and, soon after- 
ward, that the arm of the same side became weak. About the same 
time he had headache, vertigo, and weakness of sight. A short 
time subsequently — about a month, as well as he could recollect — 
the arm was seized with tremor while attempting to carry a glass of 
wine to his lips. The agitation continued to grow more violent on 
any voluntary movement of the arm, and gradually his speech be- 
came involved. 

When I saw him he was still suffering from occasional attacks of 
vertigo and headache ; the lips were agitated whenever he attempted 
to move them, the tongue was tremulous, and his speech was conse- 
quently halting and jerking. There was also nystagmus, a symptom 
which he had not noticed. 

The right arm was unaffected with tremor so long as he allowed it 
to rest on his knee or to hang by his side ; but, in the act of moving it, 
the whole extremity was agitated by a series of short, vibratory mo- 
tions, consisting of flexions and extensions, which continued so long as 
he persevered in the movement, or kept the arm in any position requir- 
ing muscular exertion. The right leg was weak, and dragged so that 
he struck his foot against any slight obstruction. There was a little 
tremor in it when he attempted to cross it over the other as he sat in a 
chair. 

1 " De la sclerose en plaques disseminees," " Nouvelle etude sur quelques points de 
la sclerose en plaques disseminees," Bourneville, Paris, 1869. 



776 CEREBRO-SPINAL DISEASES. 

I treated him solely with the primary galvanic current, which I 
passed through the brain and spinal cord — the first time such an oper- 
ation was performed in this country for the treatment of disease. My 
diagnosis was incipient softening of the ganglia at the base of the brain 
and of the upper portion of the spinal cord. My opinion was, that 
the hemispheres were not involved, as there were no symptoms indicat- 
ing mental weakness or disturbance. 

I made an application of about fifteen minutes' duration every day. 
He gradually but rapidly improved, and to such an extent that on the 
19th of April he wrote to me as follows : 

"Yesterday must be marked with a white stone as the best day yet. 
Foot active, hand and arm steady, and spirits good. If we can manage 
to fix these good effects, cure is certain. 

" I hope the magic pile will be ready to repeat its good work on 
Saturday next." 

He continued to improve for several weeks, then gradually went 
back to his former condition, and from that rapidly grew worse. The 
paralysis invaded the other side, then tremor followed, the speech 
became much more difficult, and he died in the country two years sub- 
sequently. 

Miss H., of Connecticut, aged thirty-five, consulted me for paralysis 
and tremor. About two years previously, she had noticed a "weakness 
of the right arm, which had been preceded by occasional attacks of 
not very severe headache and vertigo. The arm gradually became 
weaker, and in the course of a few months began to shake whenever 
she attempted to use it. Before the year had expired, the right leg 
began to drag a little, and lost a good deal of its natural strength. 
Her speech also became difficult, not from any failure to remember 
words, but from tremor of the tongue and weakness, with a little rigid- 
ity of the lips. 

When I saw her, the articulation was halting and syllabic ; there 
was nystagmus in both eyes ; the right arm was very weak ; she could 
only move the index of my dynamometer four degrees, equivalent to 
a pressure of two pounds and a half, while with the left hand she 
could move it twenty-eight degrees. Every attempt' to move the arm 
caused trembling of the whole extremity. So long as she refrained 
from any exertion of voluntary power, it remained free from agitation. 
She could not write, owing to the tremor which the effort to do so 
excited. There was slight tremor in the leg, when she slowly raised the 
foot from the ground. 

The mind was perfectly intact, and she was entirely free from any 
emotional weakness. 

In this lady's case I diagnosticated multiple cerebro-spinal sclerosis 
— the " sclerose en plaques disseminees " of Charcot. 

I treated her with the iodide of potassium and the primary gal- 



MULTIPLE CEREBRO-SPINAL SCLEROSIS. 777 

vanic current. By the following autumn she had improved so much 
that she could walk several miles without fatigue, lifted her foot clear 
of the ground, could move the index of the dynamometer to thirty 
degrees, was free from tremor, except when she attempted to write, 
and then it was only manifested to a slight extent. I now ceased 
using the galvanism, but continued the iodide of potassium. One 
year later she paid me a visit. She was then walking well, but there 
was still a very slight tremor when she attempted to execute delicate 
or difficult movements with the right arm. I directed the continu- 
ance of the iodide. 

Mr. H., of South Carolina, a highly-educated and intelligent gen- 
tleman, consulted me for paralysis and tremor. As he entered my 
consulting-room, the tendency to festination w r as exceedingly well 
marked. On examination, I found his mind perfectly clear. There 
were nystagmus and syllabic articulation. On moving the left arm or 
left or right leg, the limb became tremulous. There had never been 
any head-symptoms. 

One week later, at my request, he wrote a short account of his dis- 
ease, which I here transcribe : 

" I was never robust in health, but, on the other hand, I have never 
had, since childhood, a serious spell of sickness. My manner of life 
has been sedentary — that of a student. I was always careful not to 
overtask myself until I became engaged, in the year 1864, in a mathe- 
matical research. I was for a considerable length of time very much 
absorbed in this work, and allowed it to encroach seriously upon my 
hours of recreation and sleep. 

" In the fall of 1865, after having accomplished the above work, I 
observed a slight lameness in my left foot — a tendency to strike the 
toe against the inequalities of the ground — an inability to raise quickly 
enough the front part of the foot. 

"After my return home, in the summer of 1866, from Europe, 
where I had spent five or six years, the lameness in my foot in- 
creased rapidly, and in the winter of 1866-'6T a lameness in my 
left hand was very perceptible — an inability to move the fingers 
quickly, and a tremor, particularly of the thumb, when I attempted 
to do so. 

" The above symptoms have gradually grown worse, and within the 
last year the right leg has become involved, to the extent that it begins 
to shake when I stand upon it, and it shakes even while sitting, when I 
am under excitement, or when I execute difficult voluntary motions 
with my hands. 

" The disease seems to make greater progress in hot weather. I 
have at no time suffered pain, my appetite and digestion are good, and 
I generally sleep well." 

This gentleman improved greatly through the use of the primary 



778 CEREBRO-SPINAL DISEASES. 

galvanic current, iodide of potassium, and tincture of hyoscyamus, 
during the two weeks that he remained in New York under my 
care. On his return to South Carolina he took a primary-cell battery 
with him. 

Four months later he wrote to me as follows : 

" Sometimes I thought I was improving slowly, or at any rate not 
losing ground, and then again, for several days together, I would feel 
confident that I was falling back. But now I think I can certainly say 
I am growing worse. All my symptoms have been worse — lamer, more 
nervous, and the disease more general in its effects. My right hand, 
which has heretofore been comparatively unaffected, is now seriously 
implicated, and yet I still manage to write after a fashion. I find it 
very difficult to dress myself, and I must make several attempts before 
I can get up from a sitting or a lying posture. 

" What could have caused the improvement that took place while 
I was under your immediate treatment?" 

In this case I diagnosticated multiple cerebro-spinal sclerosis, and 
I think those acquainted with the disease will agree with me in my 
view of the case ; and yet there was as strongly-marked festination 
as I have ever seen. The gentleman could trot well, could mount a 
staircase without much difficulty, but walking slowly, or descending 
stairs, troubled him greatly. According to some authors, this symptom 
would, of itself, have been sufficient to contraindicate the existence of 
sclerosis, and to have placed the disease among the neuroses. My 
views on this point have already been expressed under the head of 
multiple cerebral sclerosis. 

J. F., a gentleman of this city, forty-two years of age, consulted me 
November 29, 1870. On the 4th of July previously he had indulged 
rather freely in champagne, and the following morning awoke with 
severe headache, vertigo, and nausea. Although he recovered from 
this attack, he never felt quite as well as before, and was frequently 
subject to headache and vertigo — symptomatic, as he thought, of 
gastric disorder. About a month after his first symptoms he was sud- 
denly conscious of a singular sensation about his left eye, and on look- 
ing in the glass discovered that the upper lid had dropped, and that he 
could not raise it. This was about five o'clock in the afternoon, and by 
ten that night the lid entirely covered the pupil. The following morn- 
ing it was not so low, but he found that he saw double. He continued 
to attribute all his troubles to the stomach, and began taking some quack 
remedy recommended to him for dyspepsia. 

In the course of a few days, feeling no better, he went to the sea- 
shore, and while there noticed that his right arm became weak, and that 
he frequently let things drop from his hand. He had difficulty in shav- 
ing and in dressing himself, from inability to coordinate the muscles, 
and there was numbness of the ends of the finders. During all this 



MULTIPLE CEREBRO-SPINAL SCLEROSE. 779 

time he had suffered more or less from headache, vertigo, and double 
vision, and the ptosis still continued. Gradually the left arm became 
involved, and, by the time the paresis in this extremity was well estab- 
lished, the right arm was affected with tremor, but only when he at- 
tempted to execute movements with it. Thus, as he said, he could 
place the hand on a table and it would continue perfectly quiet ; but, 
as soon as he took a pen to write, or even endeavored to raise the hand 
from the table, it was seized with tremor. The left arm soon became 
similarly affected, and eventually the left leg lost strength and was 
rendered tremulous by any attempt at muscular exertion. He noticed 
also, what, as I afterward learned, his friends had perceived several 
weeks before, that his articulation was imperfect, and that is was ne- 
cessary for him to make a mental effort to talk distinctly. 

He returned to the city about the middle of October, and employed 
a " rubber " to restore, as he said, the circulation to his limbs. Con- 
tinuing to get worse, he consulted me. 

. At this time there was festination. The speech was syllabic and 
accentuated, the tongue and lips were paretic and tremulous, there was 
nystagmus in both eyes, ptosis and diplopia from paralysis of the left 
sixth nerve, and dilated pupil of the right eye. There were also occa- 
sional headache and vertigo, but not to the same extent as at first. 

Both arms and the left leg were partially paralyzed. He could not 
raise either upper extremity out from the side, owing to the complete 
paralysis of the deltoids, but he could flex both forearms, and move his 
aands and fingers tolerably well. There was no tremor while he re- 
frained from using them, but the least attempt at voluntary motion 
excited them to agitation. The same was true of the left leg. Exami- 
nation with the ophthalmoscope showed both optic disks to be white, 
and the retinal vessels small and straight. 

With the dynamometer he could only exert a pressure of nine de- 
grees with the right hand and eleven with the left. The line made 
with the dynamograph was descending, showing his inability to main- 
tain, even for a short time, a uniform muscular contraction. 

There was no loss of sensibility, except in the upper extremities. 
He had occasionally suffered from pains in the back, about the region 
of the shoulders. 

The power over the sphincters was intact. 

This gentleman could stand and walk as well with his eyes shut as 
with them open. On rising from his chair, which he did with difficulty, 
he always felt impelled to take a few steps forward, which were a stag- 
ger rather than a voluntary movement. In walking, the body was in- 
clined forward, and he went in a kind of jog-trot. 

He attributed his disease to dissipation of all kinds, in which opinion 
I expressed my concurrence. 

Under treatment with galvanism, hyoscyamus, and iodide of potas- 



780 CEREBRO-SPINAL DISEASES. 

sium, this patient has improved, but not as vet sufficiently to warrant 
any strong hope of a permanent cure. 

A gentleman from the northern part of the State of New York con- 
sulted me in January, 1871, and again in March. His symptoms, though 
decided, were not very severe in character. Gradually, however, there 
had been for two years a loss of power supervening in the muscles of 
the right side of the body, and lately ocular troubles had made their ap- 
pearance. Tremor, on making any voluntary movement, was just be- 
ginning to appear when I last saw him. Its influence over his hand- 
writing is seen in the following facsimile: 

Fig. 113. 




One patient, with multiple cerebro-spinal sclerosis, attends the out- 
door department of the New York State Hospital for Diseases of the 
Nervous System. He has marked head-symptoms. And another, from 
Philadelphia, who was supposed to be suffering from cerebral disease, 
consulted me a few days ago. In this case the affection probably re- 
sulted from a fall. 

The remaining cases do not present any such peculiar phenomena 
as to warrant their histories being given in detail. 

Causes. — Nothing very definite is known of the etiology of the affec- 
tion in question. It probably is. induced by such causes as give rise to 
the purely cerebral form of the disease. Age does not, however, ap- 
pear to exercise so important an influence. Eleven of my cases were 
over fifty years, and one of them, the gentleman from Philadelphia, 
was over sixty ; seventeen were over forty and under fifty, and three 
were between thirty and forty. All were males but four. 

In seven cases it was apparently caused by excessive mental appli- 
cation, in two by anxiety, in one by a fall, in six by dissipation. In 
the remaining cases I could discover no obvious cause. In none of 
them was there a rheumatic, syphilitic, or other morbid diathesis. 

Diagnosis. — The facts of the tremor making its appearance after the 
paralysis, and of its only — or, at least, with rare exceptions, and then 
only in the latter stages of the disease — being manifested when volun- 
tary movements are being made, will suffice to distinguish the cerebro- 
spinal form of sclerosis from any other affection. The points to recol- 
lect are these : that, in paralysis agitans, the tremor appears before 
the paralysis, and does not depend on the voluntary contraction of 
muscles for its excitation. The tremor is rhythmical, and the muscu- 
lar movements are performed slowly on account of the stiffness and 
contraction of the muscles : In simple spinal sclerosis there is no tremor 



MULTIPLE CEREBRO-SPINAL SCLEROSIS. 781 

at all. I have already insisted on these distinctions in my remarks on 
the other forms of sclerosis of the nervous centres. 

Prognosis. — This is very generally unfavorable. In only one case 
have I had reason to expect a cure. It often happens that amendment 
very decided in its character takes place soon after the beginning of the 
treatment with galvanism and hyoscyamus. This has been the case 
in every instance of the disease that has been under my charge ; but 
in only one has it been permanent. In those now under treatment, 
there has as yet been no relapse ; but the time is too short to speak 
with any confidence in regard to the ultimate result. 

Morbid Anatomy and Pathology. — The remarks made under this 
head, when the cerebral and spinal forms of sclerosis were being con- 
sidered, apply to the cerebro-spiual variety. Charcot 1 has considered 
the subject of sclerosis mainly in its histological relations. The main 
points are — and these have already been stated several times — that the 
morbid process essentially consists in hypertrophy of the neuroglia at 
the expense of the proper nerve-substance, and that this is a conse- 
quence of inflammatory action. In the present form of the disease, the 
sclerosed tissue appears in the form of plates or nodules in different 
parts of the brain and spinal cord. 

Treatment. — The treatment of multiple cerebro-spinal sclerosis is 
more palliative than curative. Galvanism to the brain and vertebral 
column, iodide of potassium, nitrate of silver, and preparations of hyos- 
cyamus, have very generally caused improvement for a time, but my 
experience goes to show that this is not permanent. 

The galvanic current should be used of less tension when applied 
to the head, but as strong as the patient can endure, to the spine. 

The iodide of potassium, which, I believe, prevents to a certain ex- 
tent the formation of new connective tissue, should be given in mod- 
erate doses at first, but should be gradually increased up to the point 
of toleration. 

I have sometimes given the nitrate of silver in fourth-of-a-gram 
doses, three times a day, and very generally recommend cod-liver oil 
with each meal. Occasionally I have also administered the bichloride 
of mercury, with the view of counteracting a possible syphilitic dia- 
thesis. 

Hyoscyamine may be advantageously employed, according to the 
formula given on page 293, for the treatment of paralysis agitans. 

Whatever measures are adopted should be continued for several 
months at least, and, if the improvement persists, for a much longer 

period. 

1 Gazette des Hopitaux, Nos. 102, 103, 140, 141, 143. 1868. 



782 CEREBRO-SPINAL DISEASES. 

CHAPTER VIII. 

PARETIC TREMOR. 

The affection which Parkinson ' described, and to which he applied 
the name " shaking palsy," has since been very carefully studied by 
many writers, and the fact has been clearly made out that it is not a 
single disease, but includes several affections which are very different 
in character. I have already considered two of them — paralysis agi- 
tans and multiple cerebro-spinal sclerosis ; a third I propose to treat 
under the name of paretic tremor. 

Symptoms, — The primary manifestation is tremor, and this, like the 
same symptom in the severer forms of disease already considered, in 
which it forms an essential feature, may begin in a very restricted or 
more extensive region of the body. It is present whether voluntary 
movements are performed or not with the affected limbs, but is in- 
creased by mental excitement of any kind, by physical exertion, or by 
any cause capable of depressing the powers of the system. 

It is not generally the case that the tremor shows any tendency to 
advance much beyond its original limits, howsver small or extensive 
these may be. When it does exhibit such a disposition, contiguous 
muscles are first attacked, and then the corresponding ones on the oppo- 
site side of the body. 

From the very first there is slight muscular weakness, not to any 
very great extent, and often not severe enough to attract the patient's 
attention, but still sufficiently evident to careful examination with the 
dynamometer. As the tremor increases in violence or extent, the 
paralysis becomes more obvious. 

Sensibility is rarely affected, there is no bending of the body for- 
ward, no festination, and no head-symptoms. The tremor always ceases 
during sleep, except in very extreme and long-continued cases, and 
there may be intermissions of longer or shorter duration while the 
patient is awake. 

Causes. — Paretic tremor may result from emotional disturbance, 
from continuous or severe muscular exertion, from some exhausting 
disease, such as dysentery, typhoid or typhus fever, or rheumatism, or 
from blows, falls, or other injuries. In many cases the cause cannot 
be ascertained. 

Of twenty-five cases of which I have records, ten were apparently 
due to mental causes, four to excessive physical exertion, four to dis- 
eases of various kinds, two to injuries, and in five no cause could be 
discovered. 

Two cases of mercurial trembling, the symptoms of which affection 

1 "Essay on the Shaking Palsy," London, 1817. 



PARETIC TREMOR. 783 

are very similar to those of non-toxic paralysis agitans, are not included 
among the foregoing. 

Diagnosis. — From paralysis agitans, paretic tremor is distin- 
guished by the facts that there are no head-symptoms, no festina- 
tion, and no derangements of sensibility. It is more apt to occur in 
persons under the age of fifty, and may be met with in quite young 
persons. The reverse of both these circumstances is true of paralysis 
agitans. 

From multiple cerebro-spinal sclerosis, it is diagnosticated mainly 
by the absence of any head-symptoms, by the fact that the tremor usu- 
ally comes on before the paralysis, and is independent of voluntary 
movements. 

From convulsive tremor it is readily distinguished by the facts that 
the tremor is not paroxysmal, and that it is accompanied by paresis of 
the affected muscles. 

The character of the muscular action, and the history of the case, 
will prevent its being confounded with chorea. 

Prognosis. — Paretic tremor rarely terminates fatally, and when it 
does it is because the tremor has become so general that death results 
from exhaustion. It, however, often happens that all measures fail to 
relieve the agitation. Of the twenty-five cases occurring in my own 
experience, eight were cured, five partially so, and in the rest no per- 
manent effect was produced by any means I employed. 

Morbid Anatomy and Pathology. — Nothing is known of the morbid 

anatomy. In a few cases, patients have died either from the disease or 
from some intercurrent affection, and post-mortem examinations have 
been made with negative results. Petrseus, quoted by Dr. Handfield 
Jones, relates two severe cases, one of which proved fatal. At the 
autopsy nothing was found but fatty degeneration of the heart and 
pneumonic consolidation of the right lung. He remarks on the tremor 
not being constant in many cases, ceasing for some days and then re- 
turning with fresh force, or changing its seat from one part to another. 
In my opinion, the disease under consideration is due to an irregular 
and diminished evolution of nerve-force from the motor nerve-cells in 
relation with the nerves supplying the muscles in which the agitation 
exists. The pathology of tremor, not the result of structural lesions, is 
a subject which is beginning to be studied, but which is not yet clearly 
understood. We know that, when we have strongly exerted an arm, 
for instance, the muscles are tremulous for some time afterward, and 
that the agitation is rendered very evident when we attempt to write 
or do any other act requiring delicate muscular adaptation. A period 
of rest must take place before steadiness is regained. Now, in such 
a case the agitation is not probably due to any cause inherent in the 
muscle, but is the result of exhaustion in the nerve-cells and the 
disengagement of insufficient force jn an intermittent manner. I sup- 



734 CEREBRO-SPINAL DISEASES. 

pose paretic tremor to be due to some such action in the motor nerve- 
cells in the gray matter of the spinal cord. 

In those cases in which the tremor becomes permanent, structural 
lesions of profound character — as in permanent hysterical contractions 
and epilepsy — doubtless occur. 

Treatment. — I have used electricity, both of the galvanic and fara- 
daic kinds, in all the cases of paretic tremor that have been under my 
charge, and in conjunction have employed many internal medicines, 
such as arsenic, iron, manganese, zinc, copper, phosphorus, strychnia, 
and sedatives of various kinds, including opium, bromide of potassium, 
conium, stramonium, Indian hemp, and many others. I am very de- 
cidedly of the opinion that the best treatment consists in the use of the 
constant primary current to the spinal cord, sympathetic nerve, and the 
affected muscles, while at the same time strychnia and phosphorus, ac- 
cording to the formula given on page 67, are administered internally. 
By these means four of my eight successful cases were entirely cured 
within two months. One of these was sent to me by my friend Dr. F. 
N. Otis. The affection was confined to the right arm, and was probably 
due to inordinate gymnastic exercise; the other was a gentleman from 
St. Louis, in whom the disease was also confined to the right arm, and 
had apparently resulted from writing excessively. Both had lasted 
several months. 

Another was a railway engineer, in whom the disease was the result 
of over-mental excitement; and the fourth was a distinguished clergy- 
man of the Catholic Church in whom a like origin existed. 

The six other cases were, two of them, consequent on other diseases, 
and four were without known cause. Three were women ; the tremor 
in two was in both arms, and in two in one leg in each. The duration 
of the treatment was from three to seven months. A full and nutri- 
tious diet, and the avoidance of all mental excitement or strong physi- 
cal exertion, are important features in the treatment. 



CHAPTER IX. 

ANAPE1BATIC PARALYSIS. 

There is a class of paralyses produced by the habitual use of a par- 
ticular class of muscles in the same way for a long time. Thus we have 
writer's paralysis, telegrapher's paralysis, hammer paralysis, and so on. 
To describe these as separate and distinct affections is scarcely, in the 
present state of our knowledge, permissible. I shall, therefore, em- 
brace these under the designation of anapeiratic (A-vaizeipaG), to do or 



ANAPEIRATIC PARALYSIS. 785 

attempt again) paralysis, as being caused by the frequent repetition of 
some particular muscular action. 

Symptoms. — The first symptom usually observed is a feeling of fa- 
tigue experienced in the muscles which have been grouped together 
for frequent use in some especial way. Thus in writers, engravers, 
violinists, type-setters, and telegraphers, the tired sensation is felt in 
the muscles of the hand, forearm, arm, and shoulder. The thumb is 
especially affected, and is also the seat of a dull, aching pain. Pains, 
not very severe or fixed, are also common in the muscles higher up ; 
this fatigue the patient endeavors to correct by grasping the pen or 
burin, for instance, more firmly, or by making an intense mental effort 
to regulate the muscular contractions by which the instruments are 
held, the type seized, or by which the fingers are moved over the strings 
of the violin, or the lever of the telegraph-instrument. But he only 
thereby adds to the difficulty, for the weariness and pain are increased, 
the muscles become weakened, and moreover irregular and incoordi- 
nate actions ensue which render the results of either writing, engraving, 
etc., more or less imperfect. 

If he perseveres day after day in his occupation he soon reaches 
that stage of the disease in which the ability to direct the pen, for in- 
stance, in accordance with his will, is lost, and the automatic actions, 
which are of great importance in writing, are likewise very much di- 
minished. For a time, then, he writes better when his mind is not 
occupied in directing the formation of every letter, but in which he 
allows the muscles as it were to take care of themselves. Constantly, 
however, he feels the necessity of mental action, and this action invari- 
ably increases the trouble, until, at last, the moment the attempt is 
made to write, the pen, actuated by the muscles of the fingers, executes 
such disorderly movements as to bear, in extreme cases, little or no 
analogy to the words attempted to be written. A distinct paroxysm 
is thus induced, which lasts as long as the patient persists in the attempt 
to write. When he discontinues, the spasm ceases, and he can perform 
any other act with the fingers without there being the slightest convul- 
sive movements. In some cases there is pain in the fingers, the muscles 
between the metacarpal bones, and in those of the forearm. The spasm 
is much worse if the patient be excited or particularly anxious to do his 
best. 

In the accompanying woodcut (Fig. 114) are represented three 
attempts of a patient to write the name "James Ely." At first some 
resemblance to the letter J is made, but in the second trial it is less 
distinct, and in the third is lost altogether. 

All of my patients had resorted to various -expedients to obviate the 
spasms, under the idea that they were produced by metallic pens carry- 
ing off the electricity from the arm ; several had, for a time, made use 
of quills, or hard rubber pens, and for a time relief had been ob- 
51 



r86 



CEREBRO-SPINAL DISEASES. 



tained, but the paroxysms soon became as bad as ever. Others had 
used very thick pen-holders, and this expedient was also, for a time, 
successful. In the end, however, all such efforts to prevent the spasms 
proved futile. 

In one case under my charge, the patient, an engraver, was utterly 
incapable of using his burin, although he could write for hours perfect- 




ly well, and those who had contracted the disease by excessive writing 
could execute any other delicate movements, such as drawing, playing 
the piano or violin, threading needles, etc., without inconvenience. In 
several cases the individuals had acquired the power to write with the 
left hand, but before long this was also affected. 

Dr. G. V. Poore * has recently published an interesting memoir on 
the affection as produced by excessive writing, and argues that, although 
it is true that patients can execute other actions than writing with the 
affected hand, the muscles employed in these movements are not the 
same as those used in writing. This is doubtless true of advanced 
stages of the disease, but it certainly is not so of early periods. I have 
a patient at this time under my charge who cannot write without great 
inconvenience, but who uses a pencil in drawing with the greatest fa- 
cility and precision. 

Dr. Frank Smith 2 describes the disease I have designated anapei- 

1 " Writers' Cramp, its Pathology and Treatment," The Practitioner, June, July, and 
August, 1873. 

2 Lancet, March 27, 1869, also " On Hephsestic Hemiplegia or Hammer Palsy," British 
Medical Journal, October SI, 1874. 



ANAPEIRATIC DISEASES. 787 

ratio paralysis, as it occurs in workmen who use the hammer almost 
continually in certain processes, and gives it the name of hephjcstic 
(H.(paiOTog, Vulcan) hemiplegia. 

" There are numerous varieties of manufactures in which the rapid 
use of a light or heavy hammer plays a chief part, such for example as 
table-blade forging, scissors-making, saw-straightening, razor-blade 
striking, engineering, file-forging, etc." 

" The pen-blade forger uses a hammer about three pounds in weight. 
A pen-blade receives in the process of forging and joining to the piece 
of iron by which it is attached to the haft, on an average, one hun- 
dred blows. The forger, if an industrious man, anxious perhaps to save, 
by working overtime, enough money to join a building-society, or to 
commence business on his own account, will work twelve or thirteen 
hours a day. He will make as many as twenty-four dozen blades in a 
day, and in so doing will deliver twenty-eight thousand eight hundred 
accurate strokes. The rapidity and accuracy with which these blows 
rain upon the slender piece of iron are wonderful to the onlooker. Sup- 
posing him to work three hundred days in a year, and to continue this 
for ten years, he will in that period have delivered eighty-eight million 
four hundred thousand strokes, and just so many discharges of nerve- 
force will have occurred in the motor ganglia which are engaged in 
the action, and in the higher ganglia which calculate the distance and 
judge of the amount of force necessary to be evolved." 

In several of the cases adduced by Dr. Frank Smith there were 
head-symptoms, and in all more or less extensive hemiplegic paralysis. 
There were also twitchings of muscles, pains, and difficulty of speech, 
in some of the cases. 

M. Onimus l was, I think, the first to call attention to the disease as 
met with in telegraph-operators. The trouble appears usually to mani- 
fest itself in the first place by a difficulty in coordinating the muscles so 
as to make dots or points with the instrument. After a time the same 
restraint is experienced in the formation of lines. The disease appears 
to be rare in this country, which — as, according to M. Onimus, the Morse 
machine is especially apt to induce it — is somewhat remarkable. 

In several of my cases there have been symptoms indicative of dis- 
order of the central nervous system. These have consisted of headache, 
pain in the back, and occasional tremors of the limbs. In one case 
there is marked inability to coordinate the muscles of articulation so 
as to speak clearly. The trouble seems to be more in the lips than in 
the tongue, and there is decided mental impairment. In this case 
there is no doubt that the affection has originated from the excessive 
uses of the muscles of the right hand and arm in writing. 

Causes. — The disease is more apt to attack persons somewhat ad- 
vanced in life, than the very young. All my patients were over forty 

1 Gazette Medicate ; also Chicago Journal of Nervous and Mental Diseases, 1875. 



788 CEREBROSPINAL DISEASES. 

years of age. All were males, though this proclivity of men to the af- 
fection is not absolute, as several cases are on record in which women, 
seamstresses especially, have been its subjects. It is apparently some- 
times induced by using the fingers in constrained positions. In one of 
my cases, the patient, who had been in the habit of writing with the 
hand supported by the little finger, cured himself by allowing the whole 
hand to rest on the desk. The principal cause — the habitual perform- 
ance of certain restricted movements — has already been sufficiently con- 
sidered. 

The opinion which Poore expresses, that it is due in writers to the 
use of steel-pens, is not borne out by my experience. I have seen it in 
persons who always wrote with quill-pens, and, as we know, the disease 
occurs in individuals from other causes than writing. 

Diagnosis. — Attention paid to the characteristic symptoms of ana- 
peiratic paralysis, and inquiry into the clinical history, will prevent its 
being mistaken for lead-paralysis, progressive muscular atrophy, or any 
other disease. 

Prognosis. — In the early stage anapeiratic paralysis, by whatever 
cause induced, admits of cure. When it has existed a long time, and 
when the patient cannot rest, a cure is almost impossible. 

A majority of the cases that have come under my notice had lasted 
too long to admit of cure, and the patients had, notwithstanding the 
imperfections of their work, persisted in using the affected muscles in 
the actions which had led to the causation of the disease, and then when 
this was no longer possible had used the other hand in like manner, till 
it also had become affected. In such cases permanent cures are almost 
out of the question, although relief can be obtained to such an extent 
as to allow of occasional writing. 

Morbid Anatomy and Pathology. — As regards the morbid anatomy, 
there are no data, and the lesion is probably not one which can be de- 
tected by our present means of observation. The affection is, however, 
doubtless due to disorder in the normal action of the motor cells, and 
this disorder is the result of over-exertion of a particular set of muscles 
in a particular way. Examples of cerebral exhaustion by the predomi- 
nance of one idea, or a series of ideas for a long time, are often wit- 
nessed. Writer's spasm is, I conceive, the result of a similar action in 
spinal motor cells and cerebral nerve motor centres. 

Poore, however, does not believe that the affection, as met with in 
writers, can be of central origin, but certainly the symptoms are of a 
character to militate against his view. He has looked at the disease 
from too restricted a stand-point. No one can read the report of Dr. 
Frank Smith's cases without at once perceiving that they are the re- 
sults of central lesions. 

Treatment. — The most indispensable means of cure is rest, and, un- 
less this can be secured, it is useless for the physician to undertake the 



EXOPHTHALMIC GOITRE. 789 

treatment. In some cases it has succeeded without any assistance. 
The abstinence from the labor causing the disease, and sometimes from 
all continuous muscular exertion, should be absolute during at least six 
months. 

The constant galvanic current has proved the most effectual agent 
in my hands : I apply it to the sympathetic nerve, the spinal cord in its 
upper part, and to all the muscles and nerves of the upper extremity. 
A half an hour three times a week, with a current of considerable inten- 
sity (forty cells), will be sufficient. Faradization, in my experience, is 
more productive of harm than benefit. 

With the galvanism I have administered the combination of phos- 
phide of zinc, and extract of nux-vomica, recommended on page 68 of 
this treatise. 

The bromide of zinc in incipient cases is a most efficacious agent in 
restoring tone to the nervous system, and in conjunction with rest will 
often effect a cure. It should be used in gradually-increasing doses as 
recommended for convulsive tremor and chorea. 

When a cure cannot be effected, well-devised prothetic apparatus 
will enable the patient to write or perform other actions requiring skill 
rather than strength ; but I am not sure that they do not lead to the 
further extension of the disease, especially in its cerebral relations. 
Division of tendons or muscles is not admissible. 



CHAPTER X. 

EXOPHTHALMIC GOITRE. 

It is with hesitation that I have ventured to include the remarkable 
disorder called Graves's disease, Basedow's disease, exophthalmic goitre, 
and by several other designations, under the head of cerebro-spinal 
affections. But, after a careful consideration of all the points in its 
clinical history and morbid anatomy, as they have been observed by 
others, and studied by myself, I find it difficult to place it in any other 
category. The reasons which have governed me in this decision will be 
stated under another division of this chapter. 

Symptoms. — The first phenomenon to make its appearance, in a case 
of exophthalmic goitre, is irregular and excessive action of the heart. 
The organ is far more irritable than when in a state of health, and thus 
slight emotional disturbance or moderate physical exertion readily affects 
its action. Even when the patient is mentally and physically quiet, the 
pulsations are rarely below a hundred in a minute, and the least excite- 
ment, mental or bodily, will send them up to a hundred and twenty, 
a hundred and fifty, a hundred and sixty, or more, in extreme cases. 



790 CEREBRO-SPINAL DISEASES. 

With the increase in frequency there is generally an augmentation 
of the force of the heart. The patient feels its pulsations against the 
wall of the chest, feels them as the whole body is shaken by them, and 
hears them in the murmur which is constantly in the ears. 

The carotids and abdominal aorta can be seen to have their action 
increased, and the jugular veins, always dilated, are sometimes the seat 
of pulsation. 

Physical examination does not in general indicate the existence of 
any organic disorder. Sometimes, however, the heart is found to he 
enlarged, but rather as a consequence than a cause of the disturbance. 

A systolic murmur is often heard, which may be either arterial or 
ventricular. In the former instance it is anaemic, in the latter it is due 
to a relative insufficiency of the auriculo-ventricular valves. 

The next symptom in order is usually an enlargement of the thyreoid 
gland, an enlargement which is variable, and which is greater or less in 
accordance with the excessive or moderate action of the heart. Not- 
withstanding this capacity for change in size, there is a permanent 
augmentation in the volume of the body, below which the decrease 
does not take place. 

If the hand be laid over the swollen thyreoid, a peculiar sensation 
like that derived from stroking a purring cat — -fremissement cataire — 
is felt with every systole of the heart, and a bellows-murmur is heard 
when the ear is applied to the part. 

Next, the third essential phenomenon makes its appearance, and 
this consists of a prominence of the eyeballs. Usually this is sym- 
metrical, but occasionally one protrudes more than the other. In 
the early stage of the affection the lids can be closed over the eyes, 
but in extreme cases they cannot be brought together, and the con- 
junctivae are therefore exposed to the atmosphere and to particles 
of dust, which cause excessive lachrymation and sometimes trouble- 
some inflammation. 

The pupils rarely exhibit any deviation from the healthy state. I 
have sometimes found them abnormally dilated, never contracted, and 
always sensitive to light. 

A fourth and very important symptom has recently been observed 
by my assistant, Dr. Louise Fiske-Bryson, in her careful study of my 
cases at the Post-Graduate Medical School. It has never been spoken 
of before, as far as I can ascertain, and is of the greatest importance 
in regard to the prognosis of the disease. The symptom in question 
consists of a gradual and steady decline in the extent of the expansion 
of the chest on forced inspiration. In every case that I have examined 
since Dr. Bryson's discovery this deficiency has been observed. In 
well-advanced cases the expansion is only half an inch, and even less 
than that. When the expansion is less than half an inch, the prog- 
nosis is grave. 



EXOPHTHALMIC GOITRE. 791 

Graefe 1 has called attention to a circumstance which accompanies 
the protrusion of the eyeballs, and that is the disassociation of the 
movements of the upper eyelid from those of the eyes. In the nor- 
mal condition, when the globe of the eye is raised, the lid is also ele- 
vated, and when the globe is depressed the lid likewise falls. In ex- 
ophthalmic goitre these automatic movements do not take place. 

Stell weg. has called attention to the fact that in some cases there is 
a retraction of the eyelid, sometimes on one side, sometimes on both. 

These four phenomena — excessive action of the heart, enlargement 
of the thyreoid gland, protrusion of the eyeballs, and inability to ex- 
pand the chest on forced inspiration — may be said to constitute the 
cardinal symptoms of the disease, but there are cases in which the 
goitre is scarcely if at all present, and others in which the exophthalmos 
is absent, and probably others, again, in which both these phenemena 
are wanting. 

Again, there is no definite relation between the degrees of severity 
characterizing these symptoms. Sometimes the heart is most tumultu- 
ous in its action, the goitre large, and the eyes very slightly prominent, 
or the eyeballs may protrude to the utmost and the goitre be small, 
and the heart not excessively deranged, and so on. 

But though these four phenomena constitute the most marked feat- 
ures of the disease, there are others which, though not so obvious to 
others, add greatly to the distress of the patient. Thus there are gen- 
erally tremor, cough, nausea, oedema of the extremities, increase of 
temperature, profuse sweating, and occasional haemorrhages from the 
nose, lungs, or bowels. 

In two instances I have observed constriction of the visual field 
and of the color field. 

The emotional excitability I have always found increased, sleep is dis- 
turbed and insufficient, there are headache, vertigo, and noises in the 
ears, the character often undergoes a marked change, and individuals 
who were quiet and gentle become excited, suspicious, and irritable. 

Quite recently Dr. Bulkley, 2 of this city, has reported two cases in 
which there was urticaria. 

Ansemia is generally the predominant physical condition, and with 
it there is more or less mental weakness. The body is usually much 
emaciated, probably in part from defective appetite and defective as- 
similative power, which ordinarily exist. In woman, the menstrual 
discharge is almost always either entirely suppressed or greatly dimin- 
ished, and there is often profuse leucorrhoea. 

It rarely happens that there are any marked disturbances of vision, 

1 " Berne rkungen iiber Exophthalmos mit Struma und Herzleiden," Archiv filr Oph- 
thalmologic, 185Y. 

2 " Two Cases of Exophthalmic Goitre associated with Chronic Urticaria," Chicago 
Journal of Nervom and Mental Disease, October, lS'/S, p. 513. 



792 



CEREBRO-SPINAL DISEASES. 



and the movements of the eyeball do not appear to be impeded. The 
fundus of the eye, when examined with the ophthalmoscope, is gener- 
ally found to be normal ; occasionally there are venous dilatation and 
pulsation. 

The pulse, the respiration, and the heart are exceedingly erratic. 
In a series of tracings, made for me by Dr. Mary Putnam Jacobi, 
these facts were satisfactorily demonstrated. Eight consecutive pulse 
tracings, taken from the same individual, showed every variation be- 
tween a normal tracing and an modulatory line. Great variations 
were also observed in the respiration tracings and in the cardigrams. 

For the following history of a case of exophthalmic goitre, and the 
accompanying illustration from a photograph, I am indebted to Dr. J. 
B. Crawford, of Wilkesbarre, Pa. The case is particularly interesting 
from the fact that it occurred in a man, was remarkably acute in char- 
acter, terminated fatally, and that, notwithstanding the excessive action 
of the heart during life, there was no cardiac hypertrophy. 

" July 2, 1872. — Visited Colonel E. B. H., occupation, lawyer, fifty- 
three years of age, and of nervo-sanguine temperament. Has been 
afflicted with muscular rheumatism for ten years, contracted in military 
service in Virginia, in 1861 and 1862. Has been engaged in active 
business until within the past two weeks. He has at times been con- 
scious of rapid and forcible beating of the heart, increased by either 
physical or mental effort. During the past two months this has been 

steadily increasing in sever- 
Fig. 115. . T i , , ,° , 

lty. He has had much pain 

in the abdomen for a long 
time. Has had a slight cough 
and expectoration for more 
than a year. 

"About six weeks ago he 
first observed a distinct en- 
largement of the thyreoid 
gland. He remembered, how- 
ever, that during the past 
year or more he has had dif- 
ficulty in buttoning his shirt- 
collar. 

"The gland is now two 
and a half inches in diameter, 
and very prominent. He has 
marked prominence of the 
eyes, giving to his features a 
staring, wild expression (Fig. 
115). The eyeballs seem projected directly forward. There is no 
strabismus, nor perversion of sight. The eyelids are scarcely suffi- 




EXOPHTHALMIC GOITRE. 793 

cient to cover the eyeballs. Slight compression returns the eyes to 
their normal position in their sockets ; but upon removal of pressure 
they are immediately protruded to the extent of their former promi- 
nence. The lachrymal secretion is as free as usual. The action of 
the heart is exceedingly violent, its beating being distinctly observ- 
able by the movements of the patient's clothing, and numbering 123 
per minute. 

" Examination by percussion and with the stethoscope discloses no 
symptoms of hypertrophy nor evidence of valvular lesion. Area of pre- 
cordial dullness not increased. Distinct bellows-murmur is heard over 
the left ventricle — much more distinct over the arch of the aorta and 
left carotid. Fine venous murmur is heard over both thyreoids, and 
distinct arterial impulse observed over abdominal aorta on palpation. 
Breathing is vesicular, respiration twenty per minute. The skin is pale, 
the face becoming flushed when under mental excitement. The lips 
and membrane lining the mouth exceedingly pallid. The bowels are 
constipated. The patient has slept very little during the past four 
months. He appears nervous and agitated. His hands are exceedingly 
tremulous. He has lately found it difficult to write legibly or to even 
hold a pen. 

u A saline cathartic was prescribed — one-sixtieth grain of aconitia, 
to be given every six hours. Diet to be light and nutritious. Quiet, 
mental and physical, was enjoined. 

" 3d. — Patient slept several hours last night. Bowels have acted 
freely. He feels better. Pulse, 120 per minute. 

" 5th. — Has rested well. Pulse, 100. Treatment continued. 

" 7th. — Pulse, 90 per minute. Has had short paroxysms of palpita- 
tion, but no pain. His appetite is poor. Treatment continued, with 
addition of citrate of iron and extract of gentian. 

" 9th. — Symptoms unchanged. Examination of urine shows its 
specific gravity to be 1019, and strongly acid. A few small tube-casts 
are noticed. Numerous small crystals of triple phosphate, quantity 
normal. Aconitia continued. Elixir pyro-phosphate of iron and cin- 
chona, one drachm before each meal. 

" 12th. — Has slept better. Pulse, 95. No recurrence of palpitation. 
Appetite better. Protrusion of eyes less conspicuous. Patient rode 
out a short distance to-day. 

" 15th. — Pulse, 100. Condition nearly same as before. Tempera- 
ture, 98° Fahr. Exophthalmia less marked. Gradual emaciation. 

" 17th. — Consultation with Dr. C. Washburn. Patient's condition 
unchanged. Treatment continued. 

" 20th. — In consultation with Drs. Washburn and Rothrock, it was 
decided to give the following: I£. Spir. seth. co., § iv ; hydrocyanic 
acid, 3 j. M. Sig. A teaspoonful every six hours. About midnight, 
soon after taking the second dose, the patient became delirious. His 



794 CEREBRO-SPINAL DISEASES. 

son, Dr. O. F. Harvey, who was with bim at the time, states that the 
patient's face became flushed, his head hot, his feet and hands cold. 
The pulse rose to 115 per minute. 

" Ice-water was applied to his head, and hot applications to his ex- 
tremities. Delirium continued about one hour. I was sent for, and 
ordered the last -prescribed medicine to be discontinued. Aconitia to 
be given as before, with elixir valerianate of ammonia, one drachm, 
every three hours. 

" 21st. — Patient able to sit up and walk about the room. Pulse, 95. 
Appetite improved. 

" 22d. — Symptoms improved. Pulse, 90. 

il 31st. — Patient growing weaker ; otherwise but little changed. My 
own ill-health making it necessary for me to leave town for a while, 
the patient is left in care of Dr. Washburn until my return. The fol- 
lowing memoranda were made by him : 

" August 1st. — Patient about the same as yesterday. Resting very 
poorly. 

" 3d. — Changed treatment from aconite to digitalis. 

" 5th. — Not doing well under treatment with digitalis. Changed 
back again to aconite. Patient is directed to take a tablespoonful of 
whiskey in a wineglassful of milk whenever desired. 

" 7th. — The whiskey has made patient feel more comfortable. 

" 9th. — No marked change. Patient seems to be at a stand-still. 

" 11th. — Patient very much emaciated and weaker ; is scarcely able 
to expectorate the considerable mucous secretion which accumulates 
about the trachea and throat. 

" 13th. — Milk and whiskey are the only food which the patient's 
stomach will retain ; to be given freely. 

" 15th. — Returned home to-day, and again took charge of patient. 
Emaciation has increased. He is much weaker than when I last saw 
him, otherwise but little changed. He takes no food except a little 
milk and whiskey, and sleeps very little, and that, he says, gives him 
no rest, and does not refresh him. The pulse is variable, ranging from 
90 to 100 per minute. 

" 16th. — Has had an attack of severe pain in the left side of chest. 
Chloroform-liniment to be applied. One-sixth grain of sulphate of 
morphia to be given every three hours until relieved. 

"17th. — Patient feels easier. Debility increased. 

"20th. 10 A. m. — Patient has great difficulty of breathing in the 
recumbent position. Extremities cold. Pulse imperceptible at the 
wrist. Died at 1.30 P. M. 

"22d, Post mortem. — Rigor mortis well marked. The eyeballs 
and thyroid gland exhibit but little of their former prominence. Lungs 
healthy, except some old adhesions on left side ; a moderate amount of 
effusion in left pleura ; liver healthy ; gall-bladder very small ; stom- 



EXOPHTHALMIC GOITRE. 795 

ach, spleen, and intestines healthy ; heart healthy in appearance, 
somewhat below the average size, valves perfect ; aorta greatly en- 
larged through its whole extent, its calibre being one and a half inch 
in diameter ; arteries generally enlarged (or dilated) ; kidneys moder- 
ately hypertrophied, and much congested ; thyreoid gland much en- 
larged and apparently normal in texture. General emaciation ex- 
treme. Nervous system not examined." 

Causes. — Exophthalmic goitre is far more frequent in women than 
in men. Of the great number of cases occurring in my experience, 
very few were in men. Eulenburg 1 states the relation of women 
to men as two to one. Romberg and Hennock, 2 of twenty-seven 
cases, found twenty-four in females, and Cheadle, 3 but one male in 
nine cases. 

The disease is more frequent between the ages of twenty and forty 
than at any other period. All my cases were within these limits. In- 
stances, however, have been reported occurring both in younger and 
older persons. Men are stated by Jacccud to be more frequently 
affected after thirty years of age, and women under this age. 

Among the exciting causes mental shock is probably the most effi- 
cient. Four of my cases originated from this influence. It has been 
known to be developed almost instantaneously by powerful emotional 
disturbance. 

Dr. Begbie 4 has reported a case in which the disease w^as ap- 
parently caused by a wound of the head, and Graefe has adduced a 
like example. 

Diagnosis. — There is not much danger that exophthalmic goitre 
will be mistaken for any other affection by a physician familiar with 
its very pronounced characteristics. The excessive action of the heart, 
the enlargement of the thyreoid gland, the prominence of the eyeballs, 
the inability to expand the chest, the anaemic condition of the system, 
the venous murmurs, all go to make up a pathological picture, of 
which the elements are sufficiently well marked. But there are some- 
times cases of the disease met with in which some of the phenomena 
are not very decidedly shown, and, in these, care should be exercised 
before a definite opinion is pronounced. The facts that there are not 
the physical signs of organic lesion of the heart, notwithstanding its 
excessive action, that the swelling of the thyreoid communicates a pe- 
culiar thrill to the hand, and that the protrusion of the eyeballs is on 
both sides and is unaccompanied with disturbance of vision, will even 
in doubtful cases serve to render the diagnosis sure. 

1 " Die Basedow'schc Krankheit," Ziemssen's " Handbuch," u. s. w., zwolfter Band, 
II., zweite Halfte, Leipzig, 18*75, p. *75. 

2 Romberg, "Klinische Wahrnernungen und Beobachtungen," Berlin, 1851. 

3 "Exophthalmic Goitre," "St. George's Hospital Reports," vol. iv., 1869, p. 175. 

4 Edinburgh Medical Journal, 1849. 



796 CEREBRO-SPINAL DISEASES. 

Prognosis. — It is not often the case that exophthalmic goitre proves 
fatal. A few such cases are, however, on record, and therefore the 
prognosis, even as regards life and death, should be somewhat guarded. 
The expansion of the chest is an important factor in the prognosis. 
Dr. Bryson states that when the chest expansion is less than half an 
inch the case terminates fatally. I have seen this statement veri- 
fied in one case. Relative to a cure being effected, there is still more 
uncertainty, though I am inclined to think that with proper treatment 
exophthalmic goitre is not a very intractable affection ; the prospect 
of a mitigation of the severity of the phenomena may be reasonably 
held out in almost every case. Of the eleven cases occurring in my 
experience, four were permanently cured, and six more or less com- 
pletely benefited. One only, a young lady from Astoria, and the most 
extreme instance of the disease I have witnessed, resisted all treatment. 

Morbid Anatomy and Pathology. — Lesions have been found in the 
brain, the spinal cord, and the sympathetic nervous system, and in other 
cases there have been no appreciable alterations discovered in any one 
of these centres. The opinion prevailed at one time that the seat of 
the disease was in the sympathetic nerve, especially the cervical por- 
tion, and several instances in which this part of the nervous system 
was the seat of morbid process have been reported by Traube and 
Recklinghausen, 1 Trousseau and Peter, 2 Archibald, 3 and others. 

The changes observed in the sympathetic ganglia are enlargement, 
hardness and redness, granular degeneration, infiltration with round 
cells or with spindle-shaped cells, destruction of the ganglionic struct- 
ure with increase in the amount of connective tissue. Physiological 
experiments on the sympathetic nerve also prove conclusively that the 
symptoms of exophthalmic goitre can be produced artificially by this 
means. 

The arguments against this theory are certainly very convincing. 
A number of cases are recorded where no changes can be discovered in 
either the sympathetic nerve or its ganglia. Paul, 4 and Fournier and 
Ollivier, 5 have given the details of post-mortem examinations made in 
two cases of the disease in question, in which the sympathetic and all 
its ganglia were in a normal condition. Hammar, 6 in a report of a 
case of his own where no lesion of the sympathetic could be discov- 
ered, cites twenty-two other cases where autopsies were obtained. Of 
these, seven showed lesions in the sympathetic system, while in the 
fifteen remaining no sympathetic lesion could be discovered at all. 

1 " Deutsche Klinik," 1863. 

2 Gazette Hebdomadaire, 1864. 

3 Medical Times and Gazette, 1865. 

4 Berliner klin, Wochenschrift, 1865. 

5 Gazette Hebdomadaire, 1867; and Union Medicale, 1868. 

6 Upsala Lakare Forhande, vol. xxiv. 



EXOPHTHALMIC GOITRE. 797 

Two other autopsies have been reported since then, 1 one by Roose- 
velt and one by W. Hale White, in neither of which were the sympa- 
thetic nerves diseased. As to the physiological experiments, though 
it is admitted that many of the individual symptoms — such as dilata- 
tion of blood-vessels, exophthalmia, enlargement of the thyreoid gland, 
contraction of the lids, and accelerated action of the heart — can readily 
be obtained by producing artificial lesions of the sympathetic, it is well 
known that any one such lesion cannot result in all of these symptoms, 
since some of them Lre produced by paralysis and others by irritation 
of the sympathetic. I think it will be admitted that it is clearly im- 
possible for any one lesion to produce both irritation and paralysis at 
the same time. 

I am, therefore, inclined to think that in the present state of our 
knowledge we are scarcely warranted in locating exophthalmic goitre 
in the sympathetic nervous system. 

The theory of a central lesion is far more acceptable to my mind. 
In the first place, centres are known to exist grouped together within 
a small area in the medulla, lesions of which result in the appearance 
of the three principal symptoms of the disease. 

Filehne, in his now well-known experiments, produced each of the 
three symptoms in turn, and in one case all three of them together — 
a result which has never been obtained by any single lesion made on 
the sympathetic. Probably the fourth symptom — Dr. Bryson's symp- 
tom — was obtained also by Filehne, although, not knowing of its ex- 
istence, he probably did not look for it. 

In the second place, it does not seem unreasonable to attribute the 
three principal conditions of vagus paralysis, vaso-motor paralysis, and 
respiratory paralysis — which produce the four principal symptoms, 
accelerated heart action, enlargement of the thyreoid gland, exoph- 
thalmia, and diminished chest expansion — to a single circumscribed 
lesion affecting the vagus nucleus, the vaso-motor nucleus, and the 
respiratory nucleus. Polyuria, which is a frequent symptom of Graves's 
disease, can also be produced by a lesion in this region. 

Physiological research is not unsupported by post-mortem evidence. 
Dr. W. Hale White 2 has reported a case where "the sympathetic was 
found to be healthy. A series of sections were made from the lowest 
part of the medulla to the corpora quadrigemina. At the level of the 
lowest part of the olivary nucleus there was, just under the posterior 
surface of the medulla, evidence of slight inflammation. The next 
few sections were quite healthy, but those in the neighborhood of the 
sixth nerve showed considerable changes. Immediately under the 
posterior surface of the medulla, extending from the mesial line as far 
out as the restiform bodies, which were slightly implicated, were nu- 

1 Medical Record, March 31, 1889; British Medical Journal, March 30, 1889. 

2 Op. cit. 



798 CEREBRO-SPINAL DISEASES. 

raerous haemorrhages. The area occupied by these haemorrhages did 
not extend deeply, so that, except for a slight implication of the nerve- 
cells of the sixth nucleus on one side, the nerve-cells had escaped in- 
jury. The haemorrhages seemed almost entirely limited to the pos- 
terior part of the formatio reticularis, but there were two or three 
small, deep ones. They were not marked at this level, but were ob- 
served up to the lower part of the aqueduct of Sylvius." 

Dr. White believes this is the first case where organic lesions have 
been discovered in the medulla in exophthalmic goitre, but Lockhart 
Clark 1 reports a case where the "corpora quadrigemina and the me- 
dulla, particularly on its posterior part, were very soft, and, on minute 
examination, displayed the usual appearance of common softening." 

Fox 2 states that "the weak point in this theory of central origin 
seems to be that there is so seldom any dilatation of other vessels be- 
sides the thyreoidal." There is a strong probability that there is a 
general dilatation of the blood-vessels. It has been conclusively shown 
that in exophthalmic goitre the electrical resistance of the patient is 
very much diminished below the normal point. And although as yet 
there is no absolute proof, it seems plausible and probable that a gen- 
eral dilated condition of the vessels would account for the greatly 
diminished electrical resistance. 

In many instances no lesion has been discovered at all, and the 
burden of proof goes to show that exophthalmic goitre is frequently a 
reflex neurosis. It is not essential that even the fatal cases should be 
of organic origin, as a reflex irritation can readily be imagined to be 
of so powerful a nature as to produce almost total paralysis of the 
nerve-cells in the medulla, which, of course, in the present state of our 
knowledge, would be undetected after death. The theory that ex- 
ophthalmic goitre is often of reflex origin is supported by clinical evi- 
dence. Semon 3 reports a case on which he operated by means of the 
galvano-caustic < loop for the removal of multiple recurrent mucous 
polypi of the nose. Within a day or two after the operation exoph- 
thalmia of the right eye suddenly appeared. Graefe's and Stellweg's 
symptoms were both present, but there was no enlargement of the 
thyreoid gland and no increased action of the heart. Hoffmann, of 
Cologne, 4 reports a case of exophthalmic goitre which was entirely 
cured by an operation performed within the nasal cavity, and Hack, of 
Freiberg, and B. Frankel, of Berlin, both report cases where operations 
for nasal diseases have cured cases of Graves's disease. It will not be 
amiss to mention here that Mr. George Storker, of London, reports two 
cases where ordinary goitre disappeared after intranasal operations. 

1 " The Influence of the Sympathetic on Disease," E. Long Fox. 
- Fox, op. cit. 

3 Lancet, London, 1889, i., p. 789. 

4 Berliner klin. Wochenschrift, 1 888, xxv., 850. 



EXOPHTHALMIC GOITRE. 799 

As regards the morbid anatomy of the organs which are the seat 
of the more prominent symptoms of the disease, a few words are neces- 
sary. The heart is sometimes found to be the seat of structural dis- 
ease in cases of exophthalmic goitre, but these lesions — generally hy- 
pertrophy and mitral insufficiency — are themselves rather the results 
than the cause, and moreover they are not such as could, so far as our 
knowledge extends, produce either enlargement of the thyreoid gland 
or protrusion of the eyeballs. 

This enlargement of the thyreoid is due not to any proliferation of 
its proper tissue, but entirely to the increased quantity of blood enter- 
ing its vessels and distending it as water distends a sponge. The ves- 
sels, therefore, are always found enlarged far beyond their normal 
dimensions. 

The prominence of the eyeballs has been supposed to result from 
vascular turgescence in the orbit, to an increase in the amount of fat 
which this cavity normally contains, and to a fatty degeneration of the 
ocular muscles by which their tone is destroyed, and the eyeball allowed 
to protrude. These causes probably contribute to the production of 
the phenomenon. We must, however, add another still more influen- 
tial, and that is the contraction of Muller's orbito-ocular muscle by which 
action the eye is actively thrust forward. 

Treatment, — The internal medication most to be relied on in my 
experience is that of which iron, some one of the bromides- 1 — zinc pref- 
erably — digitalis, and ergot, are the primary features. These may be 
combined as in the following formula : I£ Ferri pyrophosphates, zinci 
bromidi, aa 3 j ; digitalis tinct., 3 v ; ergotae ext. fl., § iv ; M. ft. mist. 
Dose, a teaspoonful three times a day. In addition, the patient should 
drink a glass or two of malt liquor every day, and eat plentifully of 
animal food. 

Recently I have obtained such excellent results from strophanthus 
and from the carbazotate of ammonium that I use these remedies to 
the exclusion of all others, except such tonics as the condition of the 
patient seems to call for. Strophanthus was first experimented with 
by Prof. T. R. Fraser. 1 Wood 2 states that u the name Strophanthus 
kombe has t been given to the species which is believed to yield the 
kombe poison," but "BlondelV researches have shown that such a 
species as Strophanthus Jcombe does not exist ; what has been distin- 
guished by that name hitherto is simply Strophanthus hispidus." 

Experiments by Fraser, Drasche, and Zerner and Loaw 4 show that 
strophanthus prolongs the diastole of the heart, causes it to beat more 
slowly and to discharge at each contraction a larger quantity of blood 

1 Journal of Anatomy and Physiology, vol. vii., p. 141. 

2 " Therapeutics, its Principles and Practice," 1888. 

3 Merck's Bulletin, No. 5, vol. i., p. 55. 
- Wood, op. cit. 



800 CEREBRO-SPINAL DISEASES. 

into the arterial system ; at the same time the arteries become con- 
tracted. These facts are clearly expressed in an able article in the 
British Medical Journal* 

Bahadhurji, 2 who experimented with strophanthus in cooperation 
with Langgaard, of Berlin, found that strophanthus has a marked 
central effect upon the vagus. They report also that the respirations 
are at first increased, but are subsequently slower and weakened. This 
may be the result on the healthy organism, but in exophthalmic goitre, 
at least in the cases that have come under my observation, the respi- 
ration becomes slower and stronger, while the power of expansion 
becomes greater. It is therefore probable that strophanthus affects 
the central respiratory centre as well as the vagus centre. If these 
statements are true, we have in strophanthus a remedy which should 
exert a powerful influence in subjugating the four principal symptoms 
of exophthalmic goitre — namely, the exophthalmia, the enlargement 
of the thyreoid, the cardiac rapidity, the shortened resjurations, and 
the diminished chest expansion. 

Zerner and Loaw 3 have employed strophanthus with success in this 
disease. Brower 4 reports three very interesting cases which were cured 
by this drug in from four to six weeks. Three cases of my own show 
decided improvement under its use. Other observers have used it with 
advantage, but the foregoing cases are sufficient to show its practical 
utility in many instances. 

The only preparations of the drug which can be obtained are the 
tincture of strophanthus and strophanthine. The latter is hardly avail- 
able for therapeutic purposes, as its extreme potency renders its use 
dangerous. The ordinary dose of strophanthine is ^oVo °f a g ra i n J 
that of the tincture is from five to eight drops in water three times a day. 

Carbazotate of ammonium was first employed as a remedy against 
exophthalmic goitre by my assistant, Dr. A. C. Combes, at the Post- 
Graduate Hospital. Following the directions of Dr. Combes, I have 
given the remedy in pill form (each pill containing one grain of the 
drug) three times a day for the first week. In the second week two 
pills three times a day are given, and, if it can be borne, three pills 
three times a day in the third week. The physiological effects of the 
drug are very decided. At about the end of the first week the skin 
and conjunctivae assume a slight saffron color, which deepens if the 
drug is persisted in. Then a peculiarly unpleasant odor emanates 
from the body, which is identical with that produced by dirty feet, 
and can be distinctly noticed if you approach within six or eight feet 
of the patient. Following this, severe gastric disturbances show them- 

1 American Practitioner, Louisville, April 27, 18S9. 

2 "Ref. Handbook of Medical Science," vol. vi., p. 664. 

3 Wien. med. Wochenschrift, 1887. Wood, op. cit. 

4 Journ. Amer. Med. Assoc, 1889, xi., p. 626. 



EXOPHTHALMIC GOITRE. 801 

selves. It is rarely possible that patients can take this remedy longer 
than three weeks, but while they take it the effects upon the heart, 
the respiratory tract, and the exophthalmia are undoubted. In view 
of the foregoing statements the following cases may not prove unin- 
teresting : 

Case I. — Mrs. T. came to my clinic on June 19, 1889. She is 
forty-five years of age, and has passed through a good deal of worry 
and trouble. On June 19th her pulse was 120. Goitre measured fif- 
teen inches ; chest expansion was a little over an inch. The eyes were 
very prominent. She was given the carbazotate of ammonium in pill 
form — one grain three times a day after meals. The second week she 
took two grains three times a day, and the third week three grains 
three times a day. On July 5th, sixteen days after treatment, the 
pulse was reduced to 112 ; the goitre measured fourteen inches ; the 
eyes were less prominent. On July 12th, twenty-three days after 
treatment began, it was found necessary to leave off the carbazotate 
of ammonium, as the physiological effects were very decided. The 
tincture of strophanthus was then substituted, in doses of seven drops 
three times a day. On August 23d the goitre was thirteen inches in 
circumference ; pulse, 98 ; eyes much less prominent. The circumfer- 
ence of the neck over the goitre is now twelve inches and a half ; 
very little enlargement can be observed. The pulse is 88 ; the chest 
expansion, two inches ; and the prominence of the eyeballs is almost 
gone. She has not taken strophanthus or any other remedy for ex- 
ophthalmic goitre for several weeks, yet there seems to be no return 
of her symptoms. No other remedies were given at the same time 
with the carbazotate of ammonium or with the strophanthus. Her 
general health is greatly improved. 

Case II. — Mrs. J. S., aged forty-nine, consulted me on November 
1, 1889. Her eyes began to protrude three years ago. Pulse, 120 
and intermittent. The goitre was not large ; its measurement through 
its middle line and over the seventh cervical vertebra was thirteen 
inches and five eighths. The eyes were very prominent and seemed 
as if they would drop from their sockets. She complained of attacks 
of great pain in the eyeballs, lasting all day ; it felt " as if the eyes 
would burst." The chest expansion was an inch and a half. Neither 
von Graefe's nor Stellweg's symptoms were present. She complained 
of excessive thirst, tremor, excessive sweats, leucorrhcea, and a rash on 
the body. She had been treated for diabetes. She was treated with 
the carbazotate of ammonium, in doses of one grain three times a day. 
On November 6th the pulse was reduced to 100, and was quite regu- 
lar. The neck measurement was thirteen inches and three sixteenths, 
a reduction of nearly half an inch in a week. She was now under the 
physiological effects of the drug, so her treatment was changed to the 
tincture of strophanthus, in doses of seven drops three times a day. 
52 



802 CEREBRO-SPINAL DISEASES. 

She has intermitted this treatment once to go back to the carbazotate 
of ammonium for a week, but at the expiration of that time she re- 
turned to the strophanthus again. 

On November 15th she said she felt much better ; a marked dimi- 
nution in the protrusion of the right eye was noticed ; the pulse was 
100 ; temperature, 99'5° ; neck same as before. She has progressed 
steadily up to the present time. At the last visit both eyes were de- 
cidedly less protruded ; the neck measured only thirteen inches ; 
pulse, 88 ; chest expansion, two inches ; all other symptoms have dis- 
appeared. 

Case III. — John F., thirty-two years of age, consulted me on May 
4, 1890. He first noticed protrusion of the eyeballs five years previ- 
ously. At his first examination his eyeballs projected ten sixteenths 
of an inch beyond the inferior orbital ridge. The pulse was 160 ; 
chest expansion, five eighths of an inch. The neck, over the largest 
part of the goitre, measured fifteen inches. There was also myopia, 
contraction of the visual field, and contraction of the color field. 

The carbazotate of ammonium was given in the manner pursued in 
the former cases. 

On May 18th the pulse was 140 ; expansion, one and a quarter 
inches ; goitre, fourteen and a quarter inches. The tincture of stro- 
phanthus, in seven-drop doses three times a day, was now substituted 
in place of the carbazotate of ammonium, and was continued till the 
last part of June. The pulse was then 116; expansion, two inches; 
goitre, thirteen and a half inches. The patient's general condition was 
excellent, and he returned to work. 

Galvanization of the cervical sympathetic has been advocated, and 
many cures have been reported to have resulted from the use of this 
remedy alone. In my hands it has not been successful. Undoubtedly 
galvanization of the sympathetic will diminish the frequency of the 
heart-beat while the application lasts, but it does not seem to me rea- 
sonable or scientific to treat one symptom of a disease and to pay no 
attention to the root of the evil in the medulla. On the other hand, 
remedies which stimulate the vagus, respiratory, and vaso-motor cen- 
tres in the medulla cannot but be attended by beneficial results. To 
this end I not only employ the remedies previously mentioned, but 
also advocate systematic muscular exercise, which must, however, be 
carried on in a very careful manner. One of my patients, who was 
placed under the care of Dr. Henry Ling Taylor, and took a thorough 
course under that gentleman's supervision, recovered without any other 
treatment. 



SECTION IV. 

DISEASES OF THE PEEIPHEEAL NEEVOTTS 

SYSTEM. 



I do not propose to include under this head all the diseases to which 
the several nerves of the body are liable. Many of them are more ap- 
propriately considered in special treatises devoted to the eye and ear, 
and others differ merely in their situation, the essential condition being 
the same. Thus any nerve of the body may be paralyzed from injury, 
a disease, or from some contiguous affection capable of interfering with 
the due performance of its functions. It would scarcely be necessary 
in a general treatise like the present to give such paralyses sep- 
arate consideration, as their features and the treatment proper can 
be sufficiently pointed out under the head of a typical representa- 
tive. 

Besides, many affections which are often regarded as being located 
in the peripheral nervous system are really central in situation. Among 
these are various maladies characterized by paralysis, spasm, hyperes- 
thesia, and anaesthesia, which have already been considered as central 
diseases. 

I shall divide the affections of the peripheral nervous system into 
two groups ; those which are characterized by recognizable anatomical 
changes in the nerves — Organic Diseases ; and those in which such 
changes are not discoverable — Functional Diseases. The four immedi- 
ately following chapters describe known pathological conditions, and 
therefore organic diseases ; the others relate to affections, or rather 
symptoms, which are sometimes the results of structural changes in the 
nerves, and are again apparently entirely functional. In the present 
state of our knowledge it appears to be impossible to be more 
exact. 



804 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

CHAPTER I. 

NEURAL CONGESTION. 

Congestion of nerves is, as Mitchell 1 states, scarcely recognizable 
by clinical observation. My experience is limited entirely to a study of 
the phenomena exhibited by the affection artificially produced, and in 
these investigations I have followed the line which Mitchell has so 
thoroughly pursued. 

If, as he has pointed out, a nerve-trunk be subjected to the action 
of intense cold so as to be frozen, the period of congelation is immedi- 
ately followed by one of congestion, the result of the paralysis of the 
vaso-motor nerves of the part. 

Thus, if the sciatic nerve of a rabbit, for instance, be exposed, and, 
while a thin sheet of India-rubber protects it from direct contact, the 
vapor of ether or of rhigolene be thrown upon it from a vaporizer, the 
functions of the parts below — sensation and motion — are abolished, and 
remain so while the congelation lasts. 

But as the temperature rises a new set of phenomena ensues. The 
nerve loses its whiteness, and becomes pinkish, or even red, and this 
gradually disappears — without, so far as can be perceived, the animal 
suffering any marked inconvenience. But, if the operation be repeated, 
or if the congelation be continued for a long time, the nerve becomes 
permanently discolored, and the animal is rendered lame. If the nerve 
be examined with a lens, such for instance as one of those furnished 
with Nachet's simple dissecting microscope, the vessels are seen to be 
enlarged and more numerous than in the normal condition, and minute 
extravasations coming from the over-distended vessels are seen between 
the fibres. 

In man, though we cannot observe the anatomical changes, we are 
able to study, subjectively, with fullness and exactness, the symptoms 
which are due to neural congestion. 

Mitchell, 2 in reference to this point, says : "I have repeatedly chilled 
or frozen the ulnar nerve in myself with ice or ice-and-salt. The first 
effect is to cause intense aching pain, which, although most severe in 
the little finger, the outside of the third finger, and the ulnar palm, is 
also felt in the whole hand, and especially on the back of the hand at 
the space between the metacarpal bones of the thumb and forefinger. 
The pain rather suddenly ceases at a certain stage of freezing, and for a 
moment the hand feels natural. Then the ulnar distribution in the hand 
begins to be numb, and this increases till all sensibility is lost — touch, 
pain, and the thermal sense disappearing in turn. Last of all, motility, 
which very rarely is slightly affected, lessens by degrees and is lost alto- 

1 " Injuries of Nerves and their Consequences," Philadelphia, 1872, p. 56. 

2 Op. cit. } p. 59. 



NEURAL CONGESTION. 805 

gether. Soon after the part grows numb, the thermometer rises slowly, 
sense of heat is felt in the ulnar palm, and this region in my own case 
sweats excessively. At the same time the ulnar nerve at the elbow 
grows very excitable, and the least tap on the nerve causes slight pain in 
the third and fourth fingers, and sudden flexion of the first phalanges 
of all the fingers save the first, as well as adduction of the thumb. 

" The average rise of the thermometer in moderate chilling which 
does not annihilate sensation, and leaves motion but slightly impaired, 
is 2° Fahr. In more complete freezing it is in my case from 3° to 4° 
Fahr. 

" The symptoms which follow the thaw are, as I believe, due chiefly 
to congestion. The nerve remains sore at the elbow and even some dis- 
tance below and above it, while the brachial plexus may become tender 
(Waller), and, as the thawing occurs, the heart may be enfeebled and 
syncope threaten (Waller), or vertigo occur, as I have felt in my own 
case. The terminal distribution of the nerve suffers, after severe freez- 
ing, for hours or days ; the soreness of surface, numbness, prickling, and 
partial loss of power may continue, together with a certain fullness 
which is felt, and which makes itself visible to the eye. Even after 
slight freezing there may remain for hours certain uncomfortable sen- 
sations, which scarcely admit of distinct description. In one instance 
these symptoms endured for eleven days, according to Waller, and in 
my own .case they usually lasted from ten to fourteen days." 

I have several times, with the view of studying the resulting phe- 
nomena, frozen my left ulnar nerve by throwing upon the skin over it, 
where most superficial, the vapor of ether. I have not, however, been 
able to add much to the account of the symptoms given by Mitchell. 
By means of Lombard's instrument I have observed the rise of tempera- 
ture spoken of by Mitchell, but have, I think, ascertained that in the 
very beginning of the operation the temperature is slightly decreased, 
and that it is not till the freezing process is well advanced that the 
temperature rises. 

Congestion is probably the condition present in many cases of pain 
in nerves, which usually pass for neuralgia. This is, I think, especially 
apt to be the case when with the pain there is either clonic spasm or 
paralysis of certain muscles supplied by the affected nerve, or both 
these phenomena. It is also doubtless the primary condition of neu- 
ritis. 



806 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

CHAPTER II. 

ACUTE NEURITIS. 

Symptoms. — When the affected nerve is superficial it may be felt as 
a hard cord under the skin, pressure upon which causes an aggravation 
of the pain of which it is always the seat. The skin over it is gener- 
ally red, showing, therefore, the course of the nerve. 

If the nerve is a compound one, the parts to which it is distributed 
are the seat of symptoms resulting from the disturbance of physiologi- 
cal function. There is pain, and there is either spasm or paralysis, or 
both. The pain in the nerve-trunk, as well as that in the parts which 
it supplies, is increased at night, and there may be sympathetic pains in 
other and distant parts of the body. As the morbid process advances, 
the tactile sensibility in the parts of distribution become less, and after 
a time may be entirely abolished, but the perception of pain is not lost. 

Reflex excitability is diminished from the first or almost from the 
first, and the muscles supplied by the nerve undergo atrophy unless the 
disease soon subsides. The temperature of the parts to which the 
nerve is distributed is increased 3° or 4° Fahr. The electrical excita- 
bility of the nerve is at first increased, but shortly the reactions of de- 
generation (page 28) can readily be obtained. 

If the inflamed nerve is only sensory in function, as, for instance, 
the ophthalmic branch of the fifth, the manifestations are mainly as re- 
gards sensibility, although even here motility, as shown by the occur- 
rence of clonic spasms in the face, is reflectively disturbed. 

In cases of inflammation of motor nerves, spasm and paralysis are 
the chief symptoms, the latter being the permanent condition should 
the functions of the nerve not be restored. 

The skin covering the parts supplied by the diseased nerve is often 
the seat of an erythematous or bullous affection. 

In one of Mitchell's cases there was sudden oedema developed within 
three days, and a week later neural arthritis. 

It is rarely the case that acute neuritis ends in complete resolution. 
Mitchell never observed a case of the kind. Jaccoud, however, speaks 
of it as terminating either by complete cure, that is to say by a cessa- 
tion of the pain and return of the normal functions of the nerve, or by 
the supervention of permanent anaesthesia or paralysis, or both, accord- 
ing to the function of the affected nerve. 

The paralysis not infrequently met with as a consequence of long- 
continued exposure to cold is probably the result of neuritis. Duchenne * 
so regards it. Several cases of the kind have come under my notice, 
and the majority have been in the radial, the ulnar, and the posterior 
circumflex nerves. The symptoms were similar to those just detailed, 

1 " De l'electrisation localisee," Paris, 1872, p. 692. 



ACUTE NEURITIS. 807 

except that there was little or no pain. Indeed, in non-traumatic acute 
neuritis the presence of these pains is quite an exceptional circumstance, 
whereas, in the secondary form of the disease resulting from traumatism, 
pain is a prominent characteristic. 

Causes. — Acute neuritis is not often met with as an idiopathic affec- 
tion. Generally, it is caused by wounds or injuries, or, as in a case 
mentioned by Mitchell, by the extension of cancerous ulceration. 
It appears, however, sometimes to be very difficult to excite even by 
extensive injuries, or by exposure to the action of the atmosphere or 
other extraneous agents. I have repeatedly seen the trunks of large 
nerves exposed and subjected to irritations of various kinds, both in 
man and in the lower animals, without the supervention of neuritis. 
It is, however, on the other hand, common enough as a consequence of 
wounds, especially of those of a lacerated character inflicted on nerve- 
trunks. The terminal branches of nerves do not appear to be so readily 
affected. As we have seen, it may result from cold ; it is also produced 
by exudations from the tissues through which the nerve passes, and, as 
Leudet ' has shown, by the inhalation of carbonic oxide. 

Diagnosis. — From neuralgia it is distinguished by the history of the 
case, where traumatism is a feature, by the facts that the temperature 
of the parts supplied by the affected nerve is always elevated, which 
is not the case in neuralgia, by the persistence of the pain, and by the 
circumstance that, except in traumatic acute neuritis, the pain is not 
excessive. The occurrence of paralysis, spasm, or anaesthesia, or all of 
these symptoms in neuritis, and their absence in neuralgia, will also 
serve to distinguish the one disease from the other. 

From cerebral or spinal disease acute neuritis is readily diagnosti- 
cated by the absence of central symptoms and by the restricted limits 
of the morbid phenomena. 

Prognosis. — The prognosis in cases of idiopathic acute neuritis is 
not unfavorable; the disease may be entirely dissipated, leaving the func- 
tions of the nerve slightly, if at all, impaired. Sometimes, and espe- 
cially in traumatic cases, the tendency is to the continuance of the mor- 
bid process in a chronic form to the point of producing profound lesions 
of the nerve-tissue. Or, as Mitchell says, it may be the prime factor 
in the production of neuralgia, causal gia, joint-disease, and local palsies. 

Morbid Anatomy and Pathology. — The lesion generally involves at 
once both the neurilemma and the proper nerve-elements. The vessels 
are enlarged, and often extravasations take place. The connective 
tissue is increased in amount, and an exudation of serous or sero-fibri- 
nous fluid, with a tendency to coagulation, is formed. The tissues in 
the immediate vicinity of the inflamed nerve participate more or less 
in the morbid action. 

1 " Recherches sur les troubles des nerf s peripherique surtout des vaso-moteurs con- 
secutifs a l'asphyxie par la vapeur de charbon," Archives Generates de Meclecine, 1865. 



808 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

If resolution results, these products are absorbed, and the nerve 
regains its normal condition ; if, however, suppuration ensues, little 
abscesses form within the sheath of the nerve, or between its fibres; 
these latter become completely disorganized through granular degenera- 
tion, and eventually constitute an amorphous mass of oil-globules and 
debris contained within the neural sheath. 

The pathology of neuritis, like that of other diseases, is to be stud- 
ied from the stand-point of the normal physiology of the healthy 
nerve — and there is little to add to the remarks already made under 
the head of symptoms. The fact should be borne in mind that irrita- 
tions applied to a nerve-centre or a nerve-trunk are more acutely felt at 
the points of distribution of the nerve than at the seat of the irritation. 
Of course, in accordance with a well-known law, irritations made to a 
motor or compound nerve-trunk cause spasms in the muscles to which 
the nerve is distributed. The first stages of inflammation constitute an 
irritative process. Hence the clonic contractions which are present in 
the early periods of the affection. But, as the morbid action proceeds, 
the irritability and conductivity of the nerve become abolished, and 
therefore the clonic spasms cease, and voluntary power in the muscles 
supplied by the diseased nerve is lost. 

Treatment. — Mitchell, in the only case of acute neuritis of which he 
had the control from the beginning, enveloped the arm from above 
the wound to the finger-ends in bladders of ice and water ; the limb 
was elevated above the body, and one twenty-fifth of a grain of sul- 
phate of atropia, combined with one-quarter grain of sulphate of mor- 
phia, was given in solution every four hours or oftener if needed. 

Jaccoud recommends leeches, and even cups over the course of the 
nerve. The latter must certainly cause suffering, and Mitchell states 
that even leeching, though sometimes beneficial, causes great pain, and 
that the leech-bites are prone to inflame. 

In the cases of acute neuritis resulting from cold which have been 
under my charge I have obtained decided benefit from the use of the 
primary galvanic current of great intensity, the application being made 
through wet sponges drawn over the skin covering the affected nerve. 
Two applications, each lasting half an hour, should be made. Each one 
is followed by a diminution of the pain and numbness, and a lessening 
of the spasms of the muscles. 

At the same time I have employed deep injections of sulphate of 
morphia combined with sufficient sulphate of atropia to counteract its 
unpleasant effects — one-fourth grain of the morphia with the one- 
sixtieth of atropia being about the doses to begin with. Two injections 
should be made daily. I endeavor to touch the nerve with the point of 
the syringe, or, failing that, to come as near to it as possible. 

Hot applications to the inflamed nerves give a great deal of com- 
fort to the patient and assist in reducing the congestion. 



SCIATICA. 



809 



The good effects of this treatment are generally very evident, and 
a cure is ordinarily accomplished in at most a week. 

In two cases of inflammation of the radial nerve, apparently result- 
ing from long-continued exposure to cold and dampness, which have 
recently been under my care, I have applied the actual cautery along 
the whole course of the inflamed portion of the nerves. The effect 
was an arrest of the pain, the numbness, and the muscular spasms, and 
the continual relief of all the symptoms by the subsequent injections of 
morphia and atropia for two or three days. In both of these cases the 
tract of the inflamed nerve was marked by cutaneous redness. 

After the disappearance of the acute symptoms, if any anaesthesia 
or paralysis remains, it is to be treated with the induced or primary 
current, as may seem most advantageous by actual experiment. I am 
inclined to think that both currents should be used, the primary unin- 
terrupted for the relief of the anaesthesia and for improving the con- 
ductivity of the nerve, and the induced to the muscles for the restora- 
tion of their irritability. At the same time, passive motions, frictions 
with hair-gloves, and applications of hot water, are beneficial. 

It must not be forgotten that in the early stages, and all through 
the active period of the disease, alsolute rest must be as nearly as pos- 
sible secured. Every muscular contraction of a limb containing an 
inflamed nerve causes intense suffering, and can scarcely fail to aggra- 
vate the disease. 

Constitutional treatment beyond such as may be necessary to main- 
tain or increase the tone of the system is not ordinarily required. 



CHAPTER III. 

SCIATICA. 

This form of neuritis is characterized by the occurrence of pain in 
the course of the sciatic nerve and its branches, mainly in those dis- 
tributed to the skin. It may be restricted to the gluteal region and 
upper part of the thigh, or may extend to the sole of the foot or toes. 
The principal painful points are those which correspond to the sacral 
foramina, where the large and small sciatic nerves emerge from the 
pelvis ; a series corresponding to the emergence of cutaneous branches 
through the fascia, a fibular point at the head of the fibula, an external 
malleolar, and an internal malleolar. 

Sciatica generally begins as a dull, heavy ache, which gradually be- 
comes more and more intense, and which, like all the other forms of 
neuralgia, is aggravated by muscular exertion. It is subject to exacer- 
bations of violence, during which the least agitation of the body still 



810 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

further increases the intensity of the suffering. Sometimes the pain 
darts through the nerves like electric shocks, while at others it retains 
its original situation. It is often accompanied by muscular contrac- 
tions. Anaesthesia is generally present in the parts which are or have 
been the seats of the pain, and can readily be detected with the sesthe- 
siometer. 

A patient who has once had an attack of sciatica becomes thereby 
more liable to others. The nerve, after the full force of the disease is 
spent, remains in a more or less irritable state, during which it is par- 
ticularly liable to a fresh outbreak, and, even when this does not occur, 
it is quite common for the patient to be reminded, on any little extra 
excitation or exposure to cold, that he has a master ready on the least 
sign of rebellion to put the screws to his refractory subject. These 
remarks are applicable to all forms of neuritis, but they appear to me 
to be specially so to sciatica. Sometimes, even when the individual 
remains perfectly still and has committed no indiscretion, there are 
sharp, shooting pains, which follow the course of the sciatic nerve and 
its branches. 

Causes. — The etiology of sciatica is not materially different from 
that of ordinary neuritis, except so far as it is modified by local circum- 
stances. Among these latter are enlargement of the prostate gland, 
by which pressure is exerted on the nerve, various tumors of the ab- 
dominal organs, the pressure of the foetal head in childbirth, accumu- 
lations of faeces in the large intestine, etc. It is also occasionally in- 
duced by the pressure on the nerve which results from sitting long 
on a hard chair. Several cases of this kind have come under my obser- 
vation. 

I have also noticed the fact that sciatica is often developed with 
great suddenness on the patient making some unusual exertion of the 
limb. In such cases the effort is probably only the spark which lights 
up the flame. 

In regard to the influence of gout, rheumatism, and syphilis as fac- 
tors in the production of sciatica, I think there is considerable doubt. 
It is possible, in a very small percentage of cases, that these diseases 
may predispose the patient to sciatica, or may perhaps induce it pri- 
marily, but clinical evidence, at least in my experience, does not give 
much support to the rheumatic, gouty, or syphilitic origin of sciatica. 
Gowers x believes that both rheumatism and gout are " potent factors 
in the production of sciatica," but holds that "cases in which the 
syphilitic nature of the disease is certain are extremely rare." Anstie, 2 
on the other hand, remarks : " But so far from agreeing with those 
who think this (rheumatism) is a frequent case, my experience teaches 
me that it is quite exceptional ; nor do! believe that the common 
opinion could ever have arisen had it not been for the rage that exists 

1 " Diseases of the Nervous System." 2 " Neuralgia," etc. 



SCIATICA. 811 

for connecting every disease with a special diathesis which the profes- 
sion flatters itself that it understands." He is even more emphatic in 
his denunciation of gout as a cause of sciatica, and concludes with the 
remark that, in his experience, syphilis is but rarely concerned in pro- 
ducing it. 

My own clinical experience leads me to adopt Anstie's views. 
Rheumatism, gout, and syphilis are very common diseases in this 
country, and yet it is extremely rare to find an individual suffering 
from any one of them who also suffers from sciatica. My experience 
in this connection has shown that the vast majority of cases of sciat- 
ica have never suffered from rheumatism, gout, or syphilis, and that 
of the hundreds of cases of rheumatism, gout, and syphilis, a very in- 
finitesimal proportion have even had sciatica. Another factor against 
the theory of rheumatism and gout causing sciatica is that anti-rheu- 
matic and anti-goutic remedies, while they relieve the rheumatism and 
gout, fail utterly to improve the sciatica in the least. Again, no post- 
mortem evidences of gout or rheumatism can be found in the sciatic 
nerves after death. 

It is very probable that both rheumatism and gout lower the tone 
of the system to such an extent as to render the patient more liable to 
an attack of sciatica than he otherwise would have been ; but there is 
little or no evidence to show that either of these diseases directly pro- 
duces sciatica, or neuritis in any other part of the body, by direct 
action. 

Syphilis has been known, in rare instances, to cause sciatica, either 
by the pressure from gummata on the nerve-trunk or by causing in- 
flammation in the nerve-sheath by the direct action of the syphilitic 
poison in the system. In regard to the latter, I am as skeptical as I 
am that the poisons of rheumatism and gout directly produce inflam- 
mation in the sheath or substance of the sciatic nerve. 

Reports of cases of sciatica directly traceable to syphilis are un- 
common. Only two such cases have come under my observation. 

Neuromata, traumatism (which includes blows, falls, wounds, and 
muscular efforts), and intra-pelvic and extra-pelvic tumors, all produce 
sciatica by the irritation of pressure, which, if it is continued long 
enough, induces neuritis. Diseases of bones and joints cause sciatica 
by the extension of inflammation to the sciatic nerve. 

The Diagnosis is not a matter of any difficulty, though I have 
many times seen cases mistaken for diseases of the spinal cord, and 
vice versa. 

The Prognosis depends greatly on the ability to remove the 
cause. 

Morbid Anatomy and Pathology. — In mild cases, and probably m 
the initial stage of all cases, the inflammation is limited to the sheath 
of the nerve, the irritation of the delicate nervi nervorum accounting 



812 DISEASES OF TI1E PERIPHERAL NERVOUS SYSTEM. 

readily for the localized pain along the course of the nerve. In severe 
cases there is not only inflammation of the nerve-sheath, but there is 
also inflammation of the interstitial tissue, which, by its increase in 
volume, and consequent pressure upon the nerve-fibres, may induce 
atrophy and degeneration of the nerve and consequent atrophy and 
paralysis of many of the leg muscles. There is also, in the majority 
of cases, an exudation of leucocytes between the nerve and its sheath, 
which, by distending the nerve-sheath, probably accounts for some of 
the pain. 

Treatment. — It must therefore be understood, from the preceding 
remarks, that sciatica, no matter what its source of origin may be, is 
to be regarded as a neuritis, and is to be treated as such. Of course, 
if the neuritis has been induced by injury, by pressure, or by the ex- 
tension of inflammation, it is absolutely necessary that these condi- 
tions should be removed ; but by simply removing the original cause 
of the irritation, the pain is not always arrested. In the mean time 
the constant irritation of the sciatic nerve has resulted in a neuritis, 
which may remain long after the original source of irritation has been 
removed. 

Considering, then, that we have to deal with an ordinary case of 
sciatica due to exposure to cold, or that we have successfully removed 
the original cause of the sciatica, and the pain still continues, what is 
the most rational plan of treatment to be adopted ? Pathologically 
we have to deal with inflammation of the sheath of the nerve and per- 
haps of the nerve itself, and with a sero-flbrinous exudation, which is 
usually between the sheath and the nerve, but is sometimes in the 
substance of the nerve itself. Clinically we are confronted by pain, 
which may be slight or agonizing, continuous or only present on 
motion, and, in old cases, by a certain amount of atrophy of some of 
the muscles. 

For the relief of pain the remedies used should vary with the ex- 
tent of the suffering. In the most severe cases, where the suffering is 
intense, it is absolutely necessary to use morphine. When such is the 
case, it should be given hypodermically in doses amply sufficient to 
relieve all pain, and should be injected hypodermically, and not given 
by the mouth ; the fluid should be injected as near the nerve as possi- 
ble, as there is some reason to believe that morphine has a tendency to 
reduce the inflammation in a nerve when brought in contact with it. 
In milder cases, phenacetine, in a single dose of fifteen grains, which 
can be repeated in an hour if necessary, will be found to fulfill all 
requirements. Antipyrine and antifebrine can be used in place of 
phenacetine if desired. I have never seen any benefit derived from 
the internal administration of aconitine, atropine, gelsemium, or tur- 
pentine, remedies which are claimed to be very useful in relieving the 
pain of sciatica. 



SCIATICA. 813 

To relieve the neuritis itself, I depend almost entirely upon rest, 
the application of cold, and the use of electricity. 

In regard to the value of rest in the treatment of sciatica, there 
can be no doubt. Every time the leg is moved, the functions of the 
sciatic nerve are called into play. It is well known that the use of 
nerves and muscles induces a temporary congestion of the parts used, 
which would only have a tendency to aggravate a condition of already 
existing inflammation. Now, by rest I do not mean simply forbidding 
a patient to walk about, or even confining him to his bed, but I mean 
absolute rest to the limb, which can only be obtained by putting the 
patient in bed and applying a suitable splint to the leg. The splint I 
always use is the old-fashioned long splint, reaching from the axilla 
to the sole of the foot. It should be attached to the body by means 
of a bandage, and in the same manner fastened to the leg from the 
ankle upward to a point just above the patella. This leaves the thigh 
and the sole of the foot uncovered, a proceeding which is necessary 
for the proper application of the cold and electricity. The idea of 
using a splint in cases of sciatica is not original with me, though per- 
haps the method of using it is. The splint was first advocated by Dr. 
S. Weir Mitchell several years ago, and is, I believe, still frequently 
used by him. It gives the leg absolute rest, and should be used in all 
severe cases. In very mild cases it is not necessary. About every 
fourth day it should be removed, and passive movements of the joints 
and slight manipulations of the muscles should be carefully made, 
after which the splint should be readjusted. 

Cold is a most serviceable therapeutic agent. I am aware that re- 
frigerating the skin over the course of the sciatic nerve with sprays of 
chloride of methyl, ether, and other agents which produce intense cold 
has been advocated and is frequently used. I have employed these 
remedies, and, after a careful trial of them, it does not seem to me 
that they are as efficacious as a more moderate degree of temperature 
continuously applied. It is my custom now to apply cold by means 
of ice-bags packed against the posterior surface of the thigh. This 
can readily be done with the splint on if it is adjusted in the manner 
just described. My reason for preferring this form of cold is that, it 
being continuous, it soon reaches the nerve, and materially aids in sub- 
duing the inflammation ; as the cold is not intense, the skin is never 
frozen. My objection to the sprays of chloride of methyl, ether, and 
other freezing sprays is that the cold is so great that the skin soon 
freezes, and the application has to be discontinued before the bene- 
ficial results of the cold can be experienced by the inflamed nerve. 
This is particularly true of the chloride of methyl, which freezes the 
skin as soon as it comes in contact with it. It seems to me that where 
the chloride of methyl acts beneficially at all, it must do so as a 
counter-irritant, and not as a refrigerant. In my opinion the ether 



814 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

spray is far superior to it, as it is of a lesser degree of cold, and 
can therefore be applied for a much longer time ; but neither of 
these agents can compare to the almost continuous application of the 
ice-bags. * 

Electricity, when properly applied, is one of the most useful and 
important remedies we possess for the treatment of sciatica, but when 
improperly used only serves to aggravate the disease and retard the 
recovery of the patient. 

The faradaic current should not be used at all in acute sciatica. 
It is an irritating current, both to nerves and to muscles, and is there- 
fore contra-indicated. After the neuritis has disappeared and the mus- 
cles have become flabby from disease, or in old cases, where the nerve 
has been damaged and atrophy of muscles has resulted, faradaic appli- 
cations may be beneficial, but in acute sciatica it should never be used. 

The galvanic current may be applied in two ways : as a continu- 
ous current, and as an interrupted current. There is the same objec- 
tion to the interrupted galvanic current that there is to the faradaic — 
that is, that it is irritative. Both of these interrupted currents are 
antagonistic to the principle of absolute rest, which I believe to be so 
important a factor in the treatment of severe sciatica. The continu- 
ous galvanic current, on the other hand, is of great service. It allays 
pain, probably in part by the anaesthetic properties of its positive pole, 
probably in part by reducing the inflammation in the nerve. In what 
manner it relieves the neuritis is not known. It is claimed that it 
promotes the absorption of the serous exudation between the nerve 
and its sheath. However this may be, it unquestionably does relieve 
the patient, and in many instances no other remedy is necessary except 
rest. Its manner of application is as follows : The negative electrode 
should be about nine by four inches in size, and should be strapped to 
the sole of the foot by elastic bands. The positive electrode should 
be about five or six inches square, and should be applied over the glu- 
teal region, over the point where the sciatic nerve emerges from the 
pelvis. If there are any very tender spots along the course of the 
nerve, this electrode can be changed occasionally so as to cover them. 
The strength of the current should not be such as to cause much pain, 
but should fall just short of doing so. No rule as to the current- 
strength to be employed can be laid down, as the point of toleration is 
different in different individuals. The continuous current should be 
applied twice daily, if possible, certainly once a day, for about five min- 
utes at each seance. Most of the text-books recommend that at the end 
of each application of the continuous current a number of interruptions 
should be made in order to stimulate the muscles. Nothing of the 
sort should be done. It is opposed to the scientific treatment of the 
disease. It irritates the nerve, and counteracts, in part, if not alto- 
gether, the benefit derived from the continuous current. 



MULTIPLE NEURITIS. 815 

As for the internal administration of drugs, there is very little to 
be said. In those cases which are unquestionably syphilitic, of course 
anti-syphilitic treatment is indicated. In all other cases I think the 
iodide of potassium can be given, in gradually increasing doses, with 
great advantage, as it acts energetically in promoting the absorption 
of the serous exudation, and prevents, in a great measure, the forma- 
tion of new connective tissue. 

Regarding sciatica from its pathological standpoint, it seems to me 
that the measures just alluded to — that is, absolute rest, the applica- 
tion of moderate but continuous cold, and the proper administration of 
the continuous galvanic current — constitute, with proper anodynes, to 
temporarily relieve pain, the rational and scientific treatment of the 
disease. In cases of moderate severity, rest, together with galvanism, 
will be the only remedies required. 

In regard to other forms of treatment a word must be said. 

The use of colchicum, salicylic acid, salol, oil of wintergreen, and 
other anti-goutic and anti-rheumatic remedies, have not been followed 
by beneficial results in my cases, even where gout or rheumatism has 
complicated the case. Though the gout and rheumatism may yield to 
these drugs, the sciatica does not. 

Blisters or the actual cautery are serviceable, but do not compare 
to the action of continuous cold. When the case is not a severe one, 
blisters or the cautery may be substituted for the cold. 

Hypodermatic injections of various substances are frequently rec- 
ommended as curing cases of sciatica. Among these may be men- 
tioned ether, nitrate of silver, and osmic acid. Their action is so un- 
certain, and their tendency to create deep-seated abscesses is so well 
known, that I do not advocate their use. 

In severe cases, which resist all the useful forms of treatment, 
stretching the sciatic nerve may be followed by complete relief. 



CHAPTER IY. 

MULTIPLE NEURITIS. 

In multiple neuritis several nerves are affected simultaneously, or 
else, if the disease begins in one nerve, it is rapidly communicated to 
others. In the majority of cases the disease is symmetrically situated 
either in both legs, in both arms, or in all four extremities. 

Symptoms. — Sometimes the disease may be ushered in by a chill or 
by chilly sensations followed soon by a rapid rise in temperature, 
which, however, rarely exceeds 103° Fahr., or there may be no febrile 



816 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

disturbances whatever. The first local symptoms which attract the 
patient's attention are sensory in character. Numbness and tingling 
in the fingers and toes is soon followed by pain, slight at first, but 
quickly increasing in intensity until, in some instances, it is almost 
unendurable. Occasionally the pain is paroxysmal, subsiding after 
each exacerbation, but never completely disappearing. The muscles 
become painful and are tender to the touch, and pressure upon the 
nerve-trunks always gives rise to a great deal of pain. 

Paresis makes its appearance early in the disease, but is confined, 
however, to those muscles which are supplied by the inflamed nerves. 
In severe cases there may be complete paralysis. Atrophy of the 
paralyzed muscles is often a prominent symptom, and in severe and 
chronic cases progresses steadily until almost all of the muscular tissue 
has disappeared. 

The tactile sense, the temperature sense, and the muscular sense 
are always diminished and are sometimes abolished. The patellar- 
tendon reflex is invariably lost and the electrical " degenerative reac- 
tions " (see page 28) can usually be obtained except in very slight ex- 
amples of the disease. There may be other trophic changes, such as 
degeneration and proliferation of the skin, brittleness of the nails, and 
loss of hairs. 

Causes. — Alcoholism probably gives rise to more cases of multiple 
neuritis than all the other causes combined. It also follows exposure 
to cold, from some of the acute febrile diseases and from toxic condi- 
tions of the blood. 

Diagnosis. — Multiple neuritis is more liable to be mistaken for 
locomotor ataxia than for any other affection. In severe cases of 
multiple neuritis the danger of error is slight. The inflamed nerves 
are both motor and sensory in character ; hence, in addition to the 
sensory symptoms, which may be identical with those of ataxia, there 
is paralysis, atrophy of muscles, and the electrical reactions of degen- 
eration, none of which are present in ataxia except in a very advanced 
state. In mild cases of neuritis the diagnosis may be more difficult. 
In such cases there may be neither paralysis, atrophy, nor degen- 
erative reactions. As a general thing, the history of alcoholism, the 
sudden advent of the symptoms, the absence of the sharp shooting 
pains which usually are present in cases of ataxia for weeks, or even 
months, before other symptoms appear, will materially assist in the 
diagnosis. 

From anterior poliomyelitis, multiple neuritis may readily be dis- 
tinguished by the presence of sensory symptoms. 

There are no other affections with which this disease is liable to be 
confounded. 

Prognosis. — There is seldom a fatal termination to multiple neu- 
ritis unless the nerves supplying the respiratory muscles are affected. 



CHRONIC NEURITIS. 817 

If the neuritis is of alcoholic origin, the prognosis must necessarily be 
influenced by the patient continuing his pernicious habit. In ordinary 
cases recovery takes place in from one to three months ; severe cases, 
however, which are accompanied by a great deal of atrophy, may last 
for a year or more. 

Morbid Anatomy and Pathology. — The pathological changes which 
characterize multiple neuritis are similar to those which occur in acute 
neuritis and in sciatica, and do not need to be further amplified. 

Treatment. — Absolute rest is of the greatest importance. This I 
have insisted on in my remarks on the treatment of sciatica, and what 
I said then applies with equal force to multiple neuritis. If alcohol is 
the cause of the disease, it should be discontinued at once if it is possi- 
ble to do so. Hot applications over the inflamed nerves are of great 
service. They not only reduce the inflammation, but also assist in re- 
lieving pain. Electricity should be employed with caution. The 
faradaic current is irritative and should not be used at all. The gal- 
vanic current may be advantageously applied in the same manner that 
I have previously recommended in my remarks on sciatica. 

For the relief of pain, phenacetine in doses of fifteen grains may 
be given at intervals through the day. If the suffering is great, phen- 
acetin will not be effective, and morphine must be resorted to. It 
should, however, be given with discrimination and should be displaced 
by phenacetine as soon as possible. 



CHAPTER V. 

CHBOJnC NEURITIS.— NEURAL SCLEROSIS.— NEURAL ATROPHY. 

Chronic neuritis may result from an attack of acute neuritis; from 
central disease — either of the brain or spinal cord, or it may have an 
idiopathic origin. 

Symptoms. — The symptoms vary in accordance with the physiolo- 
gical character of the affected nerve. If a compound nerve is the seat 
of the lesion, the phenomena are in the main anaesthesia, paralysis, and 
muscular atrophy. If a sensory nerve is the one involved, anaesthesia, 
and perhaps nam, is the most prominent symptom. If a nerve of 
special sense is affected, there is disturbance of the function of the 
nerve as regards the related sense, and this may be either of the char- 
acter of hyperassthesia, anaesthesia, or both. If the diseased nerve is 
purely motor in function, then the results are motor paralysis and mus- 
cular atrophy. 

We have already had to consider to some extent the sclerosis and 
atrophy of spinal nerves in connection with certain diseases whose 
53 



818 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

primary seat is in the spinal cord. But such nerves may be the seat 
of the lesion in question and may give rise to symptoms similar in some 
respects to those due to disease of that part of the cord with which 
they are in anatomical and physiological relation. 

Disturbances of sensibility, usually of the nature of anaesthesia 
rather than hyperesthesia and paralysis of motion strictly limited to 
the muscles to which the affected nerve is distributed, are the first 
symptoms. These become more distinctly marked as the lesion ad- 
vances in its course, and eventually reach a full state of development. 
The electric contractility of the muscles begins to diminish early in the 
course of the disease, and reflex excitability is also lessened. 

Secondary neuritis, when resulting from spinal lesion, may affect 
either the anterior or posterior root singly of one or more nerves. In 
such cases the eccentric disturbances are connected with motion or sen- 
sibility, as the case may be. 

Chronic neuritis affecting a sensory nerve is not in general charac- 
terized by very acute pain, and this is accompanied by anaesthesia of 
the parts to which the nerve is distributed. As the disease advances 
the pain becomes less, and the anaesthesia correspondingly increases. 
The reflex excitability of the muscles to which the nerve is distributed 
is diminished for the reason that sensory impressions are not transmit- 
ted in full force along the trunk of the affected nerve, and hence are not 
promptly, if at all, converted into motor impulses. Neuritis as affect- 
ing the nerves of special sense does not come within the scope of this 
treatise. 

When a purely motor nerve, as the facial, is the seat of chronic 
neuritis, the phenomena observed relate exclusively to motion. In the 
early stage there is probably clonic spasm in the muscles supplied by 
the nerve, but ere long paralysis takes its place — atrophy and rigidity 
of the muscles soon follow. Electric contractility and reflex excita- 
bility are early impaired, the latter on account of the paralysis of the 
muscles, and not from any retardation of the passage of sensory im- 
pressions — which of course do not travel through a motor nerve — to the 
central organ. 

Chronic neuritis often exhibits a tendency to 'ascend and. to involve 
more central trunks in the inflammatory process. Mitchell speaks of 
this as a constant result. 

Causes. — The most common causes of chronic neuritis are the 
acute form of the disease and lesions of those parts of the central 
nervous system from which the affected nerves are derived. It also 
results when from any cause whatever the peripheral organs to which 
the nerves are distributed are prevented performing their normal func- 
tions. 

Chronic neuritis may originate primarily from wounds and injuries 
without necessarily being preceded by an acute attack. 



CHRONIC NEURITIS. 819 

Cold may be a factor in its causation, and, in conjunction with damp, 
probably produces most of the idiopathic cases. 

Syphilis, undoubtedly, may give rise to chronic neuritis. I am quite 
sure that several cases having this origin have been under my care — 
and the fact is admitted by Lagneau, 1 Buzzard, 2 and others. 

Diagnosis. — Chronic neuritis is distinguished from progressive mus- 
cular atrophy mainly by the circumstance that the paralysis precedes 
the atrophy, the latter being a secondary condition, while in progres- 
sive muscular atrophy it is the primary essential phenomena. The pres- 
ence of pain, the absence of fibrillary contractions, the impairment of 
the electric contractility, and the existence of anaesthesia, will further 
serve to make the diagnosis exact. Moreover, the clinical history 
cannot fail to add to the distinctive features of the two affections. 

From neuralgia it is diagnosticated by symptoms and characteris- 
tics to which attention has been drawn in the immediately preceding 
chapter. 

Prognosis. — Mitchell regards the prognosis of chronic or subacute 
neuritis as grave in proportion to the length of nerve involved, and the 
extent to which the morbid process has traveled in a central direction. 
His opinion is based rather upon the traumatic variety of the disease 
than the idiopathic. To the opinion expressed by him I would add that 
the chronic neuritis which results from central lesions is particularly 
hopeless. That due to syphilis is not generally unamenable to treatment 

Morbid Anatomy and Pathology. — The process which characterizes 
chronic neuritis is not essentially different from that which marks chronic 
inflammatory action in the white tissue of the spinal cord. It consists 
in a hyperplasia of the neuroglia and a contemporaneous atrophy of the 
nerve-tubes. The white substance of Schwann undergoes fatty degen- 
eration, and the nerve-tubes remain as dense fibrous cords. The mor- 
bid action, therefore, takes on the features of sclerosis, even to the pro- 
duction of the characteristic gray coloration. 

The main points in the pathology of the affection have already been 
mentioned, and need not, therefore, be again considered. 

Treatment. — Except in the chronic neuritis due to syphilitic infec- 
tion there is not much to do in the way of internal medication. In 
this form the iodide of potassium, given in gradually-increasing doses, 
as previously recommended for chronic basilar meningitis of like origin, 
is necessary, and will often, if the disease has not advanced too far, 
effect a cure. In all forms the primary galvanic current, of as great a 
degree of intensity as the patient can bear, should be applied to the 
cutaneous surface over the affected nerve. The conducting power of 
the skin should be increased by wetting it, and the electrodes should be 
wet sponges. If the nerve is so situated as not to be acted upon di- 

1 " Maladies syphilitiques du systeme nerveux," Paris, 1860, p. 210, el seq. 

2 " Clinical Aspects of Syphilitic Nerve Affections," London, 1874, p. 71. 



820 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

rectly, the current should be so applied as to affect it secondarily. Foi 
instance, the third nerve may be subjected to the galvanic stimulus 
by one pole being placed over the closed eye, and the other on the 
nape of the neck. The same process answers for the optic, fourth, and 
sixth nerves. Care should be taken to use a current, in such cases, of 
low tension; and, in all applications of the primary current to the face, 
this caution should be remembered. 

For the paralyzed muscles, the procedure recommended in the pre- 
vious chapter of using either the galvanic or faradaic current, or both, 
as the case may appear to demand, is equally applicable to chronic 
neuritis. 

Hypodermic injections of strychnia are useful. The initial dose 
may be about one twenty-fourth of a grain, and this may be graduallj r 
increased. The injection should be made at a point as near to the 
affected nerve as may be possible and proper. 



CHAPTER VI. 

TUMORS OF NERVES. 

The nerves, like the brain and spinal cord, are subject to morbid 
growths ; but very little is known of them either clinically or anatomi- 
cally. Gummy tumors, syphilitic in origin, and giving rise to symp- 
toms not essentially different from those just described as characteriz- 
ing chronic neuritis, are known to exist. The following case from Buz- 
zard ' was probably one of the kind in question : 

"A laborer, aged thirty-one, applied in February, 1873, with paral- 
ysis of the right lower extremity of two and a half years' standing. 
The limb was greatly wasted, and the foot could not be moved at all. 
It seemed that on getting up one morning he found his foot useless. 
No pain had preceded or followed the attack, and he had not been ill. 
Excitability to the induced current was lost in all the muscles below 
the knee, and very much diminished in the muscles at the back of the 
thigh, while it remained good in those on the anterior aspect of the 
thigh, in which also he retained voluntary power. The sensibility of 
the skin in parts corresponding to the paralyzed muscles was greatly 
diminished. There was no increased excitability to the intermitted 
constant current. The seat of paralysis corresponded completely with 
the distribution of the great sciatic nerve. There was no impairmrnt 
of the functions of the bladder, nor of the other leg. It appeared evi- 
dent that there was a lesion of the sciatic nerve alone. Although he 
positively denied any syphilitic infection, the existence of a very ugly- 
looking sore on the right leg (suggestive of a gummatous ulceration), 

1 Op. tit, p. 112. 



NEURAL PARALYSIS. 821 

which he had had for three months, made it likely that there had also 
been a gumma of the sciatic nerve, and he was accordingly ordered 
iodide and mercury. Under this treatment the sore rapidly healed, he 
gained a certain amount of power in the leg, and he described himself 
as feeling more than usually well in his general health, but in April he 
ceased to attend, so that I am unable to give the sequel of his case." 

Virchow, 1 while admitting that the nerves may be the seat of gum- 
mv tumors, declares that those most frequently affected are the optic, 
the olfactory, the third, fourth, fifth, and sixth. He refers to a case 
cited by Zambaco, in which the crural was apparently the seat of a 
gummy tumor. 

Besides the gummy tumor, nerves are subject to cancerous tumors, 
to myxomata, and to various forms of neuromata, among which the pain- 
ful tubercule is specially to be mentioned. These latter are small, and 
generally situated just under the skin. 

The treatment of neurotic tumors is not medical except for those 
which are of syphilitic origin. For these the iodide of potassium and 
mercury are the remedies which are indicated. All others require ex- 
cision. 



CHAPTER VII. 

NEURAL- PARALYSIS. 
FACIAL PARALYSIS. 

Paralysis of the facial nerve has already been considered as a symp- 
tom of several central lesions, but it may exist as an affection of alto- 
gether peripheral origin. As such, it is often known as Bell's paraly- 
sis, on account of its real nature having been first clearly pointed out 
by Sir Charles Bell. The nerve in question, the facial or portio dura 
of the seventh pair, was formerly regarded as one of sensation, and, 
in accordance with this view, was often divided for neuralgia. The 
experiments of Bell and Magendie established the fact of its being en- 
tirely a nerve of motion. 

Symptoms. — The facial nerve is distributed to nearly every muscle 
of the face. Its paralysis therefore causes such decided change of ex- 
pression as to be readily recognizable. The most marked phenomenon, 
and one which is of importance in the diagnosis, is the inability to close 
the eye of the affected side. This is due to the fact that the orbicularis 
palpebrarum has lost its contractile power, while the levator palpebrae 
superioris, not supplied by the facial, but by the third nerve, is not par- 
alyzed, and keeps the upper lid elevated. In consequence of this con- 
dition, the eye is constantly exposed to the action of the atmosphere, 

1 "Pathologie des tumeurs," French edition, tome ii., Paris, 1869, p. 454. 



822 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

and to contact with extraneous substances. The patient cannot wink, 
and thus the tears, not being distributed over the surface of the eyeball 
or carried off by the nasal duct — the tensor tarsi also being paralyzed 
— run over the lower lid, and scald the cheek. From this inability to 
wink, dust and other small particles of matter are not removed, and 
hence considerable irritation is produced. Exposure to strong light or 
to wind adds to the inconvenience. Comparative comfort may be ob- 
tained by the patient frequently closing the eye with the finger, or by 
keeping the lids together with a piece of adhesive plaster. 

The next most prominent group of symptoms is due to the loss of 
power in one lateral half of the orbicularis oris. As a consequence, 
the patient cannot purse up the mouth on that side, as in the act of 
whistling or spitting. From this loss of tonicity the saliva is not re- 
tained on the affected side of the mouth, but runs out over the lip, to 
the great annoyance of the patient. 

The muscles of mastication, the masseter, temporal, and external 
and internal pterygoid, are supplied by the third branch of the fifth 
pair of nerves, and hence the ability to chew is not impaired. The 
buccinator, the function of which, in conjunction with the tongue, is to 
press the alimentary bolus against the jaws, and thus keep it submitted 
to their action, is supplied by the facial, and hence its office is not per- 
formed. The food consequently accumulates between the jaws and the 
cheek, and it must be continually removed by the finger. 

The muscles which expand the face, as in the action of laughing or 
smiling, are supplied by the facial, and their paralysis destroys the nor- 
mal equilibrium, and hence the face is drawn toward the sound side. 
This loss of antagonism is most evident when the patient opens his 
mouth, and particularly when he laughs or smiles, for the paralyzed 
muscles, the zygomatici, and the risorius, are incapable of responding 
to the emotion, while those on the sound side contract vigorously. 

The paralysis of the occipito-frontalis and of the corrugator super- 
cilii prevents the raising of the eyebrows, or frowning, and obliterates 
all wrinkles from the brow. As Romberg remarks, there is no better 
cosmetic for elderly ladies than facial paralysis (" fur alte Frauen kein 
wirksameres Cosmeticum existirt"). 

Among other symptoms, it is noticed that the ala nasi is depressed, 
and does not expand as air is drawn in through the nostril, and that 
the articulation, especially of words containing labials, is indistinct. 

The expression of one side of the face is therefore destroyed ; it is 
a complete blank, incapable of responding to any emotion, and unable 
to execute those movements which in the normal condition are per- 
formed by its muscles. The muscles soon begin to lose their electrical 
excitability, and in a "short time, if recovery is delayed, the electrical 
degenerative reactions (see page 28) can be perfectly demonstrated. 

Such are the obvious and superficial symptoms of an ordinary attack 



NEURAL PARALYSIS. 823 

of unilateral facial paralysis. For the full understanding of other im- 
portant phenomena, a few words in relation to the anatomy and physi- 
ology of the nerve are necessary. 

The facial nerve takes its origin from the posterior border of the 
pons Varolii and the lateral tract of the medulla oblongata. Some of 
its fibres of origin may be traced to the floor of the fourth ventricle, 
and even to the lateral columns of the spinal cord. A knowledge of its 
course and connections enables us to determine with a good deal of ac- 
curacy the seat of the lesion by which it is paralyzed, and thus we have 
an important element in making a prognosis. 

From its point of apparent origin the facial passes forward and out- 
ward, resting on the crus cerebelli, and leaves the cranial cavity by 
entering the internal auditory meatus with the auditory nerve. It next 
enters the aqueductus Fallopii, and, passing through its whole length, 
makes its exit from the skull by the stylo-mastoid foramen; while in 
the aqueductus Fallopii it gives off three branches, the two superficial 
petrosal nerves, and the chorda tympani. The great superficial petro- 
sal passes to Meckel's ganglion, and through this supplies the levator 
palati and the azygos uvulae muscles ; the small superficial petrosal — 
regarded by some as a branch of the glosso-pharyngeal, though com- 
municating with the facial — runs to the otic ganglion which supplies 
the tensor-palati and tensor-tympani muscles, and also, according to 
Bernard, presides over the secretion of the parotid gland, through the 
auriculo-temporal nerve ; the chorda tympani goes to join the gustatory 
branch of the fifth, and is in part distributed with this to the tongue, 
but another portion of its fibres enters the submaxillary ganglion which 
presides over the function of the submaxillary gland. 

With this brief resumk of the anatomical and physiological points 
of the facial nerve, we are prepared to study other symptoms to which 
[ have not as yet alluded; for, in the account given, I have simply con- 
sidered the phenomena of facial paralysis when the lesion is situated on 
the distal side of the stylo-mastoid foramen. But the nerve may be 
affected farther back, and, though in such a case we have the symptoms 
already described, there are others which vary according to the seat of 
the disease. 

Thus, if the morbid process is in action above the origin of the 
chorda tympani, but below that of the petrosal nerves, the patient will 
experience a diminution but not a complete abolition of the sense of 
taste upon the corresponding side of the tongue. This fact led to the 
supposition that the chorda tympani was a sensitive nerve, but the ex- 
periments of Bernard and others have clearly shown that it is an effer- 
ent nerve, conveying influence from the brain, not to it. One of its 
actions is to increase the flow of submaxillary saliva. In addition, it 
supplies the lingualis muscle, and probably erects the papillae of the 
tongue, and modifies the circulation of this organ. When, therefore, a 



824 DISEASES OF THE PERIPHERAL NEUVOUS SYSTEM. 

lesion of the facial exists above the origin of the chorda tympani, the 
sense of taste on that side is lessened because the dryness of the mouth 
prevents the ready solution of the sapid substance. The difficulty is 
augmented through the non-erection of the papillae, and perhaps, also, 
by the change which has ensued in the circulation. This diminution of 
the sense of taste therefore shows that the lesion is seated on the cen- 
tral side of the origin of the chorda tympani nerve. 

Again, if the lesion be situated behind the gangliform enlarge- 
ment, from which the petrosal nerves arise, but anterior to the meatus 
internus, we have, of course, all the symptoms mentioned, and in addi- 
tion those due to paralysis of the petrosal. One of them is the depres- 
sion of the palatine arch on the affected side ; it hangs lower than the 
opposite one, and its edge is nearly straight instead of curved. This 
condition results from paralysis of the levator-palati muscle, which, as 
we have seen, is supplied by the great petrosal through Meckel's gan- 
glion. One of the two little muscles of the uvula being powerless, the 
other draws the uvula into a bow shape, with the concavity toward the 
sound side. The uvula and the velum are also pulled en masse toward 
the sound side by the action of the tensor palati, the other being para- 
lyzed through the implication of the small petrosal nerve. The connec- 
tion of the small petrosal through the otic ganglion with the parotid 
gland causes a diminution of the secretion of this gland when the lesion 
of the facial is in the situation described. 

Acuteness of hearing on the paralyzed side is sometimes observed, 
This is accounted for by Landouzy, 1 on the ground of the paralysis of 
the tensor-tympani muscle, which, as we have seen, is supplied by the 
otic ganglion, but Brown-S6quard attributes it to hyperassthesia of the 
acoustic nerve from vaso-motor spasm. 

This last category of symptoms, therefore, indicates the seat of the 
lesion to be at or behind the gangliform enlargement. 

When the lesion is within the cranium, we have all the symptoms 
mentioned, but they are complicated with others indicative of derange- 
ments of other nerves, or of cerebral disease. These have already been 
considered under other heads. 

In the foregoing account of facial paralysis, the unilateral form, 
which is by far the most common, has alone been considered, but both 
nerves may be paralyzed, producing what is called double facial paraly- 
sis, or facial diplegia. The condition has been well described, among 
others, by Wachsmuth, 2 and by Pierreson, 3 the latter of whom has col- 
lected twenty-eight cases as the basis of his memoir. Both sides may 
be paralyzed simultaneously, in which instance the disease is probably 
central, or one may follow the other. In either case, the face presents 

1 " De Alteration de Pome dans la paralysie faciale," Gazette 3fedicale, Paris, 1851- 
s " Ueber progressive Bulbar-Paralj se und die Diplegia facialis," Dorpat, 1864. 
3 "De la diplegie faciale," Archives Generahs 3fedecine, Aout, 1867, p. 139. 



NEURAL PARALYSIS. 825 

a complete want of expression, and the symptoms previously mentioned 
are duplicated in full. Two excellent representations of the affection 
are given in the report of a case by Mr. Wright. 1 Only one case has 
come under my observation. It was of long standing and incurable, 
I lost sight of the patient before I could have his photograph taken. 

Causes. — Cold is a prominent cause of facial paralysis. It is most 
apt to induce that form of the disease in which the lesion is external to 
the temporal bone. Exposure to intense cold, especially when the wind 
was blowing, has caused several cases in my experience. The patient 
has gone to bed feeling pretty well, and has awakened with one side of 
the face paralyzed. 

Rheumatic inflammation, occurring in the course of the nerve, may 
also induce facial paralysis, as may likewise tumors of the parotid gland ? 
or other cause capable of making pressure on the nerve. I have seen 
several cases which had resulted from sleeping with the closed hand 
under the face ; and it may occur in new-born children, as the result of 
pressure by the forceps. Wounds and injuries of other kinds may, of 
course, produce it. 

Within the temporal bone, facial paralysis may result from tumors, 
from periostitis, from caries of the petrous portion of the temporal 
bone, from disease of the middle ear, from haemorrhage into the aque- 
ductus Fallopii, and from fractures of the temporal bone. 

Within the cranium it may be caused by disease of the pons Va- 
rolii, or of the medulla oblongata, by atrophy of the nerve, by tumors, 
and as the consequence of injury. These latter do not, however, de- 
mand our notice, as they have already been considered in other connec- 
tions. 

Diagnosis. — Facial paralysis is distinguished from glosso-labio-laryn- 
geal paralysis, by the facts that in the latter the symptoms affect only 
the lower part of the face, and that they are accompanied by paralysis 
of the tongue and of the muscles of deglutition. From the facial pa- 
ralysis of hemiplegia it is diagnosticated by the marked circumstance 
that, in the latter disorder, the patient can close the eye, while in the 
former it remains wide open. There are no other affections with which 
facial paralysis can be confounded, if the slightest attention be given 
to its symptoms. 

Prognosis. — The prognosis varies according to the seat and the 
cause of the lesion, and the duration of the paralysis. If this latter is 
due to cerebral or intra-cranial lesion, or to disease existing within the 
aqueductus Fallopii, the prospect of cure is remote. But, if the lesion 
exists outside of the skull, and is capable of removal, or if the paralysis 
be the result of exposure to cold, or subjection to pressure, and if tLe 
electric contractility of the muscles be not destroyed, the case, under 
suitable treatment, will probably terminate favorably. By electric 

1 " Notes of a Case of Double Facial Palsy," British Medical Journal, 1869., p. 184. 



826 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

contractility, I do not mean the ability to respond to the excitation of 
the induced current, for this is lost at an early period in the majority 
of cases, but to contract upon the application of as strong a piimary 
current as can with safety be applied to the face. 

In deep-seated lesions, if a clinical history of syphilis can be made 
out, the prognosis becomes more favorable. 

If the affection has lasted a long time, and if contractions of the 
paralyzed muscles from atrophy have taken place, the probability of 
recovery is very slight, even if there is some glimmering of electro- 
contractility. 

Morbid Anatomy and Pathology. — When facial paralysis results 

from cold, it may be from consequent neuritis, or from inflammation 
excited in contiguous parts. In the latter case lymph is effused and 
pressure is exerted upon the nerve. Most of the other causes act by 
the pressure they make on the nerve, and, though, as in the case of 
sleeping with the fist under the face, the action may not be long con- 
tinued, the consequence is very lasting. The effects of pressure upon 
a nerve are experienced when we sit too long in one position, so as to 
compress the sciatic nerve, or when persons go to sleep with one arm 
thrown over the back of the chair on which they are sitting. The axil- 
lary plexus is compressed, and paralysis, more or less complete, of the 
muscles supplied by it, is the result. Several such cases have come 
under my observation, and the resulting paralysis is generally most dif- 
ficult to remove. 

The fact that in the affection now under notice the orbicularis pal- 
pebrarum is paralyzed, while in facial paralysis, symptomatic of cere- 
bral disease, such as haemorrhage, it escapes, is to be explained by the 
circumstance that in the latter disease all the fibres of origin of the 
nerve are not involved, while in the former the whole trunk of the 
nerve is subjected to the morbid process, and hence all the muscles 
which it supplies are paralyzed. 

Treatment. — The indications are : to remove the cause if possible ; 
to put the nerve under the best possible conditions for regaining its 
lost power; and to preserve the organic integrity and irritability of the 
muscles till this can take place. When there is reason to suspect the 
existence of a syphilitic taint, and the growth of exostoses of syphi- 
litic character in the aqueductus Fallopii, the iodide of potassium with 
the bichloride of mercury should be given, according to the formula on 
page 313. In several cases I have succeeded in effecting cures by this 
treatment, conjoined with electricity, when the latter by itself had pro- 
duced no improvement, or the iodide may be given alone in gradually- 
increasing doses, as recommended for chronic basilar meningitis. 

For the restoration of the nerve-function, we can do little beyond 
securing healthy nutrition of the general system, by the use of propei 
hygiene and tonics. Among the latter, strychnia is especially useful. 



NEURAL PARALYSIS. 827 

It should be employed persistently and in gradually increasing doses, 
till some evidence of its physiological action is obtained. For this 
purpose I make use of a solution of the sulphate of strychnia in the 
proportion of one grain to the ounce of water. Every ten minims of 
such a solution contain ^ of a grain of the medicine. Generally I 
begin with ten minims of this solution three times a day for the first 
day ; the next day eleven minims are given three times ; the next 
twelve, and so on, till the patient experiences a sensation of cramp or 
rigidity in the legs, or in muscles of the back of the neck or of the 
jaw. Usually the cramp is first felt in the calves of the legs. The 
further administration is now stopped, and, if necessary, on the fol- 
lowing day the solution is given as before, in doses of ten minims, and 
the doses are again run up to the extent of producing the muscular 
cramp. As illustrative of the action of this method, I cite the follow- 
ing case from my note-book. It is one of twenty- eight others in 
which the practice referred to was adopted. 

Miss S., in coming from Newark to Xew York, on the evening of 
January 5, 1878, opened the car window over the seat on which she 
sat. She experienced no inconvenience till the following morning, 
when on awaking she found that the left side of the face was par- 
alyzed. On the 7th she came under my observation. Examination 
showed that not only were all the muscles of the face supplied by the 
facial nerve paralyzed, but that there was a diminution of the sense of 
taste on the sile of the tongue corresponding to the paralyzed side of 
the face, that the left palatine arch was straighter and lower than the 
right, and that the uvula was concave toward the paralyzed side, 
while this organ and the velum were drawn over toward the sound 
side. These phenomena indicated that the lesion or morbid process 
was situated behind the gangliform enlargement. 

I at once began the administration of the strychnia, according to 
the formula just given, placed the hook (to be more specifically men- 
tioned directly) in the angle of the mouth on the left side, and advised 
the use of the faradaic current for a few minutes every alternate day. 
On the tenth day, while taking the g 1 ^ grain of the strychnia, she felt 
a little rigidity of the muscles of the calves of the legs. It was so 
slight, however, that I advised the continuance of the increasing doses. 
But even now the improvement was evident. She could close the eye 
of the affected side, elevate and corrugate the brows, and slightly re- 
tract the angle of the mouth. When she laughed, however, the right 
angle of the mouth was retracted much farther than the left. 

But soon after taking the third dose of twenty-one minims, on 
the following day, she experienced very decided cramps in both 
legs, which, however, passed off in less than half an hour. On 
the next morning I saw her. The action of the facial muscles was, 
so far as I could see, equal on both sides. There was no relapse. 1 

1 " On an Improved Method of Treating Facial Paralysis," St. Louis Clinical Record, 
May, 1878. 



828 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

I have never found blisters or liniments to be of the slightest ser- 
vice. 

The third indication is to be met by passive exercise, such as can be 
produced by pinching and kneading the muscles, and, above all, by the 
persistent use of electricity. Without this latter agent facial paralysis 
cannot be cured. 

If the induced current will cause the muscles to contract, it should 
be employed. One pole is placed over the nerve at its exit from the 
stylo-mastoid foramen, and the muscles of the paralyzed side are sep- 
arately excited by the other. A seance should last about fifteen 
minutes, and should be repeated every alternate day, or every day in 
bad cases. 

If the induced current will not cause contractions, the primary in- 
terrupted current should be used for the purpose. Care should be taken 
not to employ a current of too great a degree of intensity, as serious 
consequences have resulted to the vision by neglect of this precaution. 
As a rule, three or four milliamperes will be sufficient. Means must 
be taken to interrupt the current, as contractions are only produced 
when the circuit is closed and opened, but if the interruptions produce 
vertigo the strength of the current must be diminished. When the 
primary current has been employed for a few weeks, it will generally 
be found that the induced will cause the muscles to contract, in which 
case it should be substituted. 

The first muscle to recover power is usually the orbicularis palpe- 
brarum, but several weeks, and sometimes months, are requisite to 
bring about a complete cure. 

As an additional measure, which is serviceable in restoring the 
muscles of the mouth, the use of a very simple apparatus calculated to 
relax them is to be recommended. It consists of a hook made of hard 
rubber or whalebone, or some other suitable substance, which is caught 
into the angle of the mouth on the paralyzed side, and then attached 
to the corresponding ear by means of an elastic band. The first to use 
such an appliance, so far as my knowledge extends, was Dr. William 
Detmold, 1 of this city, who, in an old case of facial paralysis, obtained 
great benefit from its application. His apparatus consisted of a piece 
of silver wire bent into a hook at one end, for the angle of the mouth, 
and then bent again at the other end, and carried over the top of the 
ear somewhat after the manner of a pair of spectacles. The elastic 
band, such as is used to keep letters together, is, I think, an improve- 
ment. 

PARALYSIS OF THE THIRD KEEYE — MOTOR OCULI. 

Symptoms. — The motor-oculi nerve which supplies the upper eyelid, 
the superior, inferior, and internal recti muscles, the inferior oblique, and 

1 "Facial Paralysis treated by a New Method," New York Medical Journal, May, 1873, 
p. 491. 



NEURAL PARALYSIS. 829 

indirectly, through the ophthalmic ganglion, the circular, or constrict- 
ing fibres of the iris, has already been considered in its central patholo- 
gical relations. It is, however, the seat of peripheral disease, either 
intrinsic or as a consequence of lesion of the contiguous tissues. When 
the trunk of the nerve is the seat of disease or subjected to pressure, the 
symptoms consist of ptosis or a drooping of the upper eyelid, external 
strabismus from the action of the uncompensated external rectus mus- 
cle, and dilatation of the pupil from the uncompensated action of the 
dilator pupilaris muscle. 

The patient, therefore, presents a remarkable appearance. The up- 
per eyelid hangs down over the cornea, almost but not quite, in extreme 
cases touching the lower lid ; the eyeball is turned outward, and, from 
the destruction of the parallelism of the axes, double vision is produced 
and the pupil is more or less widely dilated and insensible to the stimu- 
lus of light. 

The external rectus and the superior oblique of all the extrinsic 
muscles of the eyeball remain unparalyzed, but as all the antagonizing 
muscles are powerless, they are in a state of tonic contraction, and the 
mobility of the eye is hence destroyed. 

Generally, however, in peripheral paralysis of the third nerve, the 
muscles most frequently affected are the levator palpebral superioris, 
or the internal rectus, or both ; and the branches supplying these parts 
are therefore alone involved. 

Cases of the kind are not uncommon. An interesting case came 
under my observation not long since in consultation with Drs. T. B. 
Sterling and T. C. Finnell. Recovery took place under suitable treat- 
ment, but, some six months afterward, the patient, a boy, about twelve 
years old, was brought to me by his mother on account of a recurrence. 
A cure was again easily effected. In this case the disease was appar- 
ently the result of reflex action from the stomach. The regulation of 
the diet, the internal use of strychnia, and the application of the fara- 
daic current to the closed eye in both instances relieved the condition 
in a couple of weeks. 

Causes. — Peripheral paralysis of the third nerve may be induced by 
syphilitic or other tumors compressing the nerve, by rheumatic exuda- 
tions along its course acting in like manner, by blows upon the eyeball, 
or by other injuries ; by currents of cold air blowing upon the eye, or 
by reflex irritations, such as indigestible food or worms in the aliment- 
ary canal. The two latter are especially active causes in children. 

Diagnosis. — From central disease peripheral paralysis of the motor 
oculi nerve is readily distinguished by the absence of "head-symp 
toms." 

Prognosis. — This depends very much upon the cause. If the paral- 
ysis results from pressure it will continue so long as the factor remain? 
in operation. Syphilitic tumors are more readily removed by constitu 



830 DISEASES OF TEE PERIPHERAL NERVOUS SYSTEM. 

tional treatment than any others. These latter may, however, in some 
oases, be gotten rid of by surgical operation. When the affection is 
induced by wounds or injuries, recovery is probable unless the structure 
of the nerve has been seriously impaired. When it is caused by cold, 
rheumatic exudations, or reflex irritations, recovery is the rule. 

The Morbid Anatomy and Pathology scarcely call for any additional 
remarks ; and the Treatment is to be conducted upon the same princi- 
ples as those laid down for facial paralysis. It is, however, worthy of 
special mention that the tension may be advantageously taken from the 
muscle of the upper eyelid by the use of a thin piece of India-rubber, 
which is to be attached to the lid and to the skin above it by collodion, 
as recommended by Dr. John Van Bibber, of Baltimore. 

Division of the external rectus may, in old cases, be necessary for 
the obviation of the strabismus. 

Paralysis of the sixth or abducens nerve, by which the eye, owing 
to the loss of power in the external rectus and the uncompensated ac- 
tion of the internal rectus, is turned inward and double vision produced, 
has a like clinical history, and is to be treated upon like principles. 

The same may be said mutatis mutandis of other peripheral paraly- 
ses, as, for instance, of the muscles of the larynx, of the deltoid, and of 
the muscles supplied by the radial nerve. 

Relative to this latter, the radial, M. Panas ' has shown that the 
paralysis to which it is liable is not, as generally supposed, the result 
of cold, but of slight pressure, to which it is often subjected, and M. 
Desplats 2 adduces additional arguments in support of this view. 

The latter cites the following case, the details of which were given 
to him orally by MM. Panas and Raynaud: 

In 1874 there was in the wards of M. Raynaud, at the Lariboisiere, 
a patient affected with phthisis, and who was suddenly one night taken 
with paralysis of the left radial nerve. At the morning visit the fact 
was noticed and the cause sought for. The patient habitually slept on 
the right side, and the idea of compression was therefore dismissed, the 
paralysis being attributed to cold. But a neighboring patient stated that 
he had seen the paralyzed man sleeping with his left arm lying on the 
table by the side of his bed, and his head resting on it. This satisfac- 
torily accounted for the paralysis. In the course of a few days it was 
cured by electrization. But a few days afterward the patient died. 

The post-mortem examination of the nerve was made with great 
care by MM. Panas and Raynaud, and they both remarked that at the 
point where the compression had been made the nerve was of a very 
decided ochrey color. The portion thought, to be injured was examined 

1 " De la paralysie reputee rheumatismale du nerf radial," Archives Generates dt 
cine, 1873, p. 657. 
Des paratysies peripheriques," Paris, 1875, p. 61. 



NEURAL SPASM. 831 

in the laboratory of the College of France, but no further alteration was 
detected. This was not remarkable, as the functions of the nerve had 
been restored for several days. 



CHAPTER VIII. 

2TEURAL SPASM. 

Theee are two affections which may be taken as the types of pe- 
ripheral spasm in general : these are spasm of the facial muscles — the 
mimic or histrionic spasm of Romberg, the convulsive tic of the French 
— and torticollis, or the spasm in the muscles of the neck supplied by 
the spinal accessory nerve. 

FACIAL SPASM. 

The spasms in the disease under notice may be either clonic or tonic, 
the former being by far the more common. In the clonic form, the 
muscles of the face, or a portion of them, generally on one side, are 
suddenly and violently contracted, and as suddenly relaxed. Some- 
times, the angle of the mouth is drawn back; again, the upper lip and 
the alse of the nose are elevated ; and again, the spasm affects the or- 
bicularis palpebrarum. In a case formerly under my charge, occurring 
in a gentleman from Rahway, New Jersey, both orbicularis muscles 
were affected with clonic and tonic spasms, the eyes sometimes being 
closed for several minutes at a time. 

The spasms come on in paroxysms which are of variable duration. 
I have seen them last continuously for over an hour. Generally, they 
continue from a few seconds to one or two minutes, and are repeated 
at intervals of about the same time. They may generally be excited by 
emotional disturbance of any kind ; by muscular exertion, by a current 
of wind, or other cause capable of exciting reflex actions. In the case 
above referred to, they are always induced by walking. They can be 
made to cease by pressure upon the facial nerve at various points, and 
they are generally arrested by powerful mental occupation and by 
sleep. 

In the tonic form of the affection the spasm persists, and causes 
more or less distortion of the face. It interferes with articulation, mas- 
tication, and especially with emotional expression. 

The tendency is for either form to become habitual, and hence to 
lie difficult of cure. 

Causes. — Cold is a common cause, as are also wounds and injuries, 
and carious teeth. I have seen two cases recently, from this last-named 
influence. 



832 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

The Diagnosis calls for no special consideration, and the Prognosis 
depends very much upon the duration. Generally, it is unfavorable. 

There are no facts bearing on the Morbid Anatomy, and the 
Pathology is to be explained by the principle of reflex excitation 
which, in this case, probably takes place through the intermediation 
of the fifth pair ; by reference to th'e facts ascertained by the experi- 
ments of Fritsch and Hitzig, Nothnagel, Ferrier, Bartholow, and my- 
self ; or by the theory of irritation existing somewhere in the course of 
the facial nerve. The latter is probably the most common condition. 
The analogy with chorea is very great. 

Treatment. — Of fourteen cases that have been under my charge, six 
were cured. The means which I have found most useful are, daily 
hypodermic injections of a mixture in water of five drops of Fowler's 
solution, and the one-fiftieth of a grain of atropia, and the daily use of 
the galvanic current to the facial nerve and the convulsed muscles. 

In several cases I have obtained good results from permanent press- 
ure over the facial nerve. The gentleman previously referred to had 
had, at my suggestion, a steel spring constructed, which terminated in 
two pads, and which he wore over the head in such a way as to com- 
press the facial nerves at their exit from the stylo-mastoid foramen. 
While he wore it he had no spasms, but he was unable to endure the 
pressure longer than a couple of hours. 

In one case, that of a young gentleman, from the interior of this 
State, in whom the disease had lasted about a year, a permanent cure 
was produced within a month by the use of the bromide of zinc in gradu- 
ally-increasing doses, as recommended for convulsive tremor, and the 
employment of the primary galvanic current to the skin over the facial 
nerve and affected muscles. 

Division of the affected muscles has been practised with very mod- 
erate success. 

TOKTICOLLIS. 

In this disease the spasms — which, as in the corresponding affection 
of the face, may be either clonic or tonic — occupy the sterno-cleido- 
mastoid, the trapezius, the rhomboid, and the levator-anguli scapulae, 
separately or collectively. The movements of the head in the clonic 
form depend upon the seat of the spasms, the action being in the direc- 
tion of the tractile force of the affected muscles. Sometimes the con- 
tractions are very rapid, and again they are slow and regular ; as in 
facial spasm, they are aggravated by emotional excitement or physical 
exertion. They cease during engrossing mental occupation, and during 
sleep. Occasionally both sides are affected. 

The reverse as regards facial spasm, the tonic form, is much the 
more common, and it is to it that the term torticollis is usually applied 
by surgical writers. The sterno-cleido-mastoid is generally its exclu- 
sive seat. The contraction is often accompanied by pain. 



NEURAL SPASM. 833 

Causes. — The etiology is not essentially different from that of facial 
spasm. 

Diagnosis. — There is no difficulty about the diagnosis of the clonic 
variety. The tonic form is, however, liable to be confounded with a 
similar affection so far as appearances and consequences go, which is a 
veritable myositis, but which is not an affection of the nervous system. 
The transitory character of the latter affection and the severe pains are 
sufficient diagnostic marks. 

Prognosis. — The prospect of recovery from the clonic form is very 
remote. Of ten cases that I have had under my charge, four only were 
cured. 

Of the Morbid Anatomy, or of the Pathology, nothing is known, 

though the disease may be regarded as similar in its pathology to facial 
spasm. 

Treatment. — I have made use of every remedy, in the clonic form, 
which could in my opinion be of service. Iron, belladonna, arsenic, 
morphia, chloral, chloroform, ether, bromide of potassium, strychnia, 
zinc, and many other medicines, have all failed. In one case I adminis- 
tered morphia hypodermically in gradually-increasing doses, till at last 
two grains were given twice a day, but without any permanent effect. 
I have divided the muscles in four cases without benefit. In one of 
them I cut both sterno-cleido-mastoids, the left trapezius at its inser- 
tion into the occipital bone, the left levator-anguli scapulae, and finally, 
with the concurrence of my friend Prof. Markoe, the left complexus. 
But as soon as one muscle was cut another became affected, and, after 
the division of the complexus, the expectation of obtaining a cure by 
myotomy was given up. The patient, a lady, from the South, remained 
affected for several years, but when I last heard from her she 
had greatly improved, the disease having apparently exhausted its 
power. 

Electricity in any form has never cured a case in my hands, though 
I have employed it steadily, for weeks at a time, both as the primary 
and induced currents. The induced current, however, may be used with 
advantage to the muscle of the opposite side as a means of improving 
its nutrition and strength. 

In two of the successful cases, many means were tried without suc- 
cess. In one, that of a young man from Newark, in addition to other 
means, I divided the right sterno-cleido-mastoid muscle twice, and it was 
afterward cut by my friend Prof. Sayre. All the operations were un- 
successful, although, as in the other cases, an apparatus was worn to 
prevent the too rapid union of the muscle. This patient was finally 
cured with large doses of the bromide of potassium. 

In another case, that of a lady of this city, every means used failed, 
till I tried the oxide of zinc; she began with doses of two grains three 
times a day, which were gradually increased. When she reached fifteen 
54 



834 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

grains at a dose, the spasms ceased and did not return. The bromide 
of zinc is preferable to any other form of the remedy. 

For the tonic variety, myotomy is the proper remedy, and it is gen- 
erally successful if a suitable apparatus be subsequently worn. 

Atropia administered hypodermically, as recommended by Da 
Costa, 1 has been of great service in two cases, but in both it was used 
in conjunction with the bromide of zinc and faradization of the non- 
spasmic muscles. I began with the one hundred-and-twentieth of a 
grain at a single daily injection, and gradually increased to the one 
twenty-fifth. In one case, a lady about forty years of age, recovery 
took place in five weeks; and the other, a young man twenty years of 
age, in about a month. 

My experience leads me to the conclusion that division of the 
affected muscles, even if not immediately successful, is an important 
adjunct in the treatment, and it may with this object be repeated sev- 
eral times. The effect is to give predominance to the opposing muscles, 
indirectly doing what faradization is intended to accomplish. This is 
especially true of the sterno-mastoid muscle, the usual seat of the mor- 
bid action. 

In an interesting article, Dr. John W. Ogle 2 discusses the question 
of the propriety of division of the sterno-mastoid and spinal accessory 
nerves. Thus far no great success appears to have followed the opera- 
tion. 



CHAPTER IX. 

NEURAL ANESTHESIA. 

Almost any part of the body may be deprived of sensation from 
causes acting on the peripheral nerves. One of the most familiar ex- 
amples of this fact is the anaesthesia produced in the foot and leg by 
pressure on the sciatic nerve in the act of sitting too long in one posi- 
tion; another is the loss of sensibility produced in the hand and arm by 
pressure on the ulnar nerve as it passes over the elbow. 

Anaesthesia originating from cerebral, spinal, or cerebro-spinal causes, 
has already been considered, and the present remarks will be strictly 
limited to the anaesthesia of peripheral origin. 

ANAESTHESIA OF CUTANEOUS NERVES. 

Symptoms. — The symptoms of anaesthesia from peripheral causes do 
not vary materially from those which result from central lesions. They 

1 "Pennsylvania Hospital Reports," 1868, p. 392. 

2 " Clonic Spasmodic Contraction of the Muscles of the Neck possibly having its 
Origin in some Affection of the Contents of the Spinal Canal," " London Clinical Society's 
Reports," vol. vi. 



NEURAL ANESTHESIA. 835 

consist of the various sensations of numbness, such as tingling, "pina 
and needles," a feeling as if ants are crawling over the skin, water 
trickling over it, and, in complete cases, of absolute abolition of sensi- 
bility. The conducting power of the nerve may be impaired in so 
much as only to cause a retardation of the velocity of excitations, and 
thus an impression made on the terminal extremities of a nerve is not 
felt for a much longer time than would normally be the case. Periph- 
eral anaesthesia may be accompanied with disorders of nutrition from 
irregularity of blood-supply. One form of the affection, of which I have 
seen several examples, and which probably owes its complication to 
vaso-motor spasm, is characterized by unnatural whiteness and shrink- 
ing of the skin, usually in the hands. If an incision be made, little or 
no blood escapes. In a young lady from Savannah, who was under my 
charge a short time since, this condition existed to an extreme degree, 
but disappeared with the removal of the anaesthesia. In former times, 
the test for the identification of witches consisted in finding a spot 
which could be pricked with a sharp instrument without the suspected 
person feeling the wound and without blood flowing. As many sup- 
posed witches were of highly-nervous temperaments, it is probable there 
were parts of their bodies into which pins could be stuck without caus- 
ing pain or loss of blood, owing to the existence of vaso-motor spasm 
such at that mentioned. Anaesthesia of peripheral origin in the cuta- 
neous nerves is sometimes accompanied by more or less loss of power, 
but in such cases the larger branches of the nerves must necessarily be 
involved. 

In cutaneous anaesthesia there is always a diminution of temperature 
in the affected part, and this is readily detected by comparison with 
the corresponding healthy part by means of Dr. Lombard's thermo-elec- 
tric apparatus. 

Sensations are sometimes perverted. Hot bodies applied to the skin 
may feel cold, and cold bodies hot. Again there is usually a loss of the 
power to discriminate differences of temperature even when they are 
considerable. 

The ability to distinguish slight differences in weights is usually 
lost, from the fact that the sense of pressure upon the skin is dimin- 
ished or abolished. If, however, the difference be great, the muscles 
will detect it independently of the sense of cutaneous pressure. The 
sense of touch may remain, and that of pain be abolished — or vice 
versa. I have repeatedly observed, in cases in which I have applied 
the ether-spray to the skin for the purpose of preventing the pain 
of the actual cautery, that the patient has felt the pressure of the 
white-hot instrument, but has been absolutely insensible to the 
burning. 

The aesthesiometer affords a ready means of determining the com- 
parative and absolute loss of sensation in an anaesthetic region, and will 



836 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

often be of great service in the formation of a diagnosis teiween vari- 
ous subjective feelings and true insensibility. 

There are certain diseases of the skin which are accompanied with 
anaesthesia. The principal of these are lepra anaesthetica, alopecia 
areata, pellagra, acrodynia, and Norwegian leprosy. In such instances 
the cutaneous insensibility is probably not the primary condition, but is 
secondary to the special skin-disorder. 1 At the same time the symmet- 
rical character of some of these affections is, by some authorities, re- 
garded as evidence of their dependence upon derangement of the ner- 
vous system. 

Causes. — Peripheral cutaneous anaesthesia may be produced by a 
variety of causes. Among the chief are w T ounds and injuries of various 
kinds, whereby the nerve is divided or its conducting power impaired ; 
pressure such as that caused by tumors, tight clothing, or accidental 
influences; rheumatism; exposure to intense cold, such as that produced 
by ice and salt or the ether-spray; the action of certain drugs, such as 
aconite locally applied; frequent immersion of the hands in hot water 
impregnated with soap, as in washer-women; or of the body and ex- 
tremities in sea-water, as in the men and women who take bathers into 
the ocean; and diseases of the nerves. 

Diagnosis. — The important point in the diagnosis of peripheral an- 
aesthesia is the discrimination between it and the anaesthesia, due to 
central causes. The elements of the diagnosis have been dwelt upon 
at some length by Romberg, and perhaps needlessly so, for there can 
scarcely be a case in which any difficulty in forming a correct opinion 
can arise except in those cases of anaesthesia in which the fifth pair is 
involved, and they will presently be more especially considered. As 
regards the cutaneous nerves, the existence of a peripheral cause, and 
the non-existence of evidences of cerebral or spinal derangement, will 
be sufficient indications of the nature of the affection. It could scarcely 
happen that anaesthesia, the result of central lesions, could exist with- 
out other marked symptoms being present, not connected with cases of 
peripheral origin. 

Prognosis. — This depends very much upon the cause, and the ability 
to remove it. In cases of simple division of a nerve, union may be 
effected after a time, and the functions restored, but, if any considerable 
portion of the nerve has been destroyed, the case is hopeless. Even 
when the cause is removed, as may be accomplished for instance in 
cases due to pressure, a long period often elapses before complete res- 
toration takes place. 

1 For a full account of this subject the reader is referred to two papers on " The Re- 
lations of the Nervous System to Diseases of the Skin," by Dr. L. D. Bulkley, in the 
Archives of Electrology and Neurology for November, 1874, and May, 1875, and to "A 
Memoir on Neuroses of the Skin," read before the New York Neurological Society, by 
Dr. F. Le Roy Satterlee, and published in the Psychological Journal for May, 1875. 



NEURAL ANAESTHESIA. 837 

The Morbid Anatomy aad Pathology call for but few remarks after 
what has already been said. The lesion, whatever it may be, or the 
functional disturbance if there be no lesion discoverable, is probably 
situated in the extreme terminations of the cutaneous branches ; for 
otherwise we should expect to find loss of muscular power more fre- 
quently associated with the anaesthesia than is actually the case. 

But M. Chapoy ' has shown that there are exceptions to this rule, 
and especially in regard to the radial nerve; for, in cases of injury or 
disease of this nerve causing paralysis of motion in the muscles supplied 
by it, the tactile sensibility is in the majority of instances preserved. 
This circumstance is explained by the fact that, as MM. Arloing and 
Tripier 8 have shown, numerous anastomoses exist between the radial 
and ulnar nerves. 

Treatment. — The most important therapeutic measure consists in 
the removal of the cause. Unless this can be effected, it is useless to 
attempt other treatment. If this can be accomplished, electricity is 
the most efficient agent to be employed toward restoring the irritability 
to the nerves. Sometimes the primary current is to be preferred, at 
others the induced. In the latter case the wire brush should be used 
as one of the electrodes, and the anaesthetic parts be stroked with it at 
each seance. 

AX^ESTHESIA OF THE FIFTH PAIR. 

Symptoms. — These vary according to the seat of the lesion. If the 
ophthalmic branch alone be implicated, the anaesthesia is situated in 
the forehead, the upper eyelid, the conjunctiva, and the lining mem- 
brane of the nostril. Irritating substances, therefore, coming "in con- 
tact with the eye or the pituitary membrane, are not felt, though as 
regards the latter the sense of smell remains. 

If the trouble is limited to the superior maxillary branch, the skin 
of the upper part of the face and the teeth of the upper jaw are in- 
sensible. When the inferior maxillary branch is affected, the temporal 
region, the skin covering the upper and lower jaw, the under lip, the 
chin, the lining membrane of the mouth, the anterior third of the 
tongue, and the teeth of the lower jaw, lose their sensibility ; mastica- 
tion becomes difficult, and the saliva flows from the mouth. In either 
of these cases the seat of the lesion must be anterior to the Gasserian 
ganglion. When all the branches of the fifth are involved, and, as a 
consequence, anaesthesia exists throughout the whole of one side of the 
face, it is very certain that the ganglion is affected, or that the main 
trunk of the nerve is itself the seat of the disease. Anaesthesia of the 
fifth nerve due to lesion of the Gasserian ganglion, or of the main 

1 "De la paralysie du nerf radial," These de Paris, 1874. 

8 " Recherches sur la sensibilite des teguments et des nerfs de la main," Archive* 
dc physiologie, 1869, p. 33. 



838 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

trunk, is very generally accompanied by disorders of nutrition and de- 
rangement of the senses of sight, smell, and taste. Fungoid growths 
on the gums and defective circulation in the face are common in such 
cases ; but ulceration of the cornea and congestion of the conjunctiva 
do not occur unless the lesion is situated in the Gasserian ganglion, or 
anterior to it in the ophthalmic branch. 

The Causes of peripheral anaesthesia of the fifth pair are analogous 
to those which produce the corresponding affection in the cutaneous 
nerves, cold being the chief among them. Rendu, 1 in his very complete 
monograph, expresses the opinion that the majority of the cases of 
anaesthesia of the fifth pair are due to neuritis. 

The Diagnosis requires a few special remarks, and these may be 
stated in the form of Romberg's propositions : 

" a. The more the anaesthesia is confined to single filaments of the 
trigeminus, the more peripheral the seat of the cause will be found to 
be. 

" b. If the loss of sensation affects a portion of the facial surface, 
together with the corresponding facial cavity, the disease may be as- 
sumed to involve the sensory fibres of the fifth pair before they separate 
to be distributed to their respective destinations ; in other words, a 
main division must be affected before or after its passage through the 
cranium. 

" c. When the entire sensory tract of the fifth nerve has lost its 
power, and there are at the same time derangements of the nutritive 
functions in the affected parts, the Gasserian ganglion, or the nerve in 
its immediate vicinity, is the seat of the disease. 

" d.'. If the anaesthesia of the fifth nerve is complicated with dis- 
turbed functions of adjoining cerebral nerves, it may be assumed that 
the cause is seated at the base of the brain." 

The Prognosis, the Morbid Anatomy, the Pathology, and the Treat- 
ment, require no remarks additional to those made when peripheral cu- 
taneous anaesthesia was under consideration, except that, as regards 
the treatment, if the primary current is employed, care should be taken 
that the tension be not too high, a point to which reference has already 
frequently been made. 



CHAPTER X. 

NEURAL HYPERESTHESIA (NEURALGIA). 

Under this head I propose to consider the principal painful affec- 
tions embraced under the term neuralgia. No designation in medical 
nomenclature has been more abused than this. Any pains, the origin 
1 " Des anesthesies spontanees," Paris, 18^5, p. 107. 



NEURAL HYPERESTHESIA. 839 

of which cannot readily be ascertained, and many which are well 
known to depend upon central lesions, are called neuralgic. I pro- 
pose, in the present remarks, to include under it those affections 
only which, so far as can be ascertained, are not due to disease 
either of the brain or spinal cord, but the seat of which is in the 
nerves themselves. Following the classification of Valleix, I shall 
consider — 

a. Neuralgia of the fifth pair. 

b. Cervico-occipital neuralgia. 

c. Cervico-brachial neuralgia. 

d. Dorso-intercostal neuralgia. 

e. Lumbo-abdominal neuralgia. 

f. Crural neuralgia. 

NEURALGIA OF THE FIFTH PAIR OF NERVES. 

Symptoms. — Either division of the fifth pair of nerves may be the 
seat of the disease, or all may be simultaneously affected. 

1. Ophthalmic Division. — This branch of the fifth is distributed to 
the side of the nose, the eyelids, the lachrymal gland, the globe of the 
eye, the conjunctiva, the forehead, and the scalp. The long root of the 
ciliary ganglion communicates with the nerve, and anastomoses take 
place with the superior maxillary branch. 

Valleix has shown that there are particular spots in which neuralgic 
pains are always more severe than in others, and that these are the 
points where the nerve either passes through a foramen in a bone, or 
penetrates a fascia. In the ophthalmic nerve several of these points 
are to be found. The most prominent is in the nerve as it passes out 
of the supra-orbital foramen to ramify on the forehead and scalp ; an- 
other is seated in the upper eyelid ; another in the long nasal branch 
as it passes to the skin through the line of union of the nasal bone with 
the cartilage ; another is located in the eyeball, and another at the 
inner angle of the orbit. Besides these which are peculiar to the oph- 
thalmic branch, there is another situated near the parietal eminence, and 
which corresponds to the inosculation of various branches. 

The most common form of neuralgia affecting the ophthalmic divis- 
ion of the fifth nerve is hemicrania. The occurrence of the paroxysms 
is marked by a tendency to periodicity. The pain is exceedingly sharp 
and lancinating, and occupies the frontal, temporal, or parietal regions, 
being especially intense at the point corresponding to the supra-orbital 
foramen, or at least that situated near the parietal eminence. It fre- 
quently happens that this latter spot is the only part affected. The 
paroxysm usually comes on in the morning, and rarely lasts longer than 
twenty-four hours ; frequently it disappears at nightfall. The pain is 
greatly aggravated by mental or physical exertion, by loud noises or 
bright lights. It is often complicated with nausea and vomiting, in 



840 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

which case it constitutes what is known as sick-headache. In other 
cases the pain is mainly confined to the eyeball and the accessory parts. 
There is then lachrymation, from the fact that the lachrymal gland is 
supplied from the ophthalmic division, and there may be visual troubles 
from the relation which the nerve bears to the ciliary ganglion. 

This form may also be distinctly periodical in its occurrence, and it 
rarely lasts longer at one time than twenty-four hours. 

2. Superior Maxillary Division. — The distribution of this branch 
is to the teeth of the upper jaw, the lower eyelid, the side of the nose, 
the upper lip, to the lining membrane of the nose and mouth, and to 
the temple and cheek. It inosculates freely with the ophthalmic divis- 
ion, and is in intimate relations with the spheno-palatine ganglion. 

The painful points of Valleix for this nerve are, in the infra-orbital 
nerve as it emerges from the infra-orbital foramen to be distributed to 
the lower eyelid, the side of the nose, and the upper lip; over the most 
prominent part of the malar bone, where the nerve is very superficial ; 
an uncertain point on the gums of the upper jaw ; a similar point on 
the upper lip, and another on the palate. Neuralgia of this division 
occurs in paroxysms, and may, like that of the ophthalmic, be periodi- 
cal in its attacks. 

3. Inferior Maxillary Division. — This nerve is distributed to the 
cheek, the tongue, the lower jaw and teeth, and to the sub-maxillary 
gland. It is also in connection with the otic and sub-maxillary gan- 
glia. 

Its painful points are a spot on the auriculo-temporal branch, just 
in front of the ear ; another on the inferior dental nerve, where it 
emerges from the inferior dental canal, through the mental fora- 
men. 

It is generally the case that facial neuralgia is limited to one side, 
but both are sometimes affected. It may also be confined to very 
restricted boundaries, the extreme terminal branches alone being in- 
volved. 

Causes. — According to my experience, facial neuralgia is rarely met 
with in young persons, but is more common during adult life. It is 
certainly more apt to attack females than males, and is often transmit- 
ted by hereditary influence. 

The most common exciting cause is, in this country, malaria, and 
this is especially the case with the affection in the ophthalmic division, 
as manifested in hemicrania and supra-orbital neuralgia. This latter is 
often popularly known as " brow-ague." 

Among other causes are to be mentioned mental excitement, anxi- 
ety, intense intellectual exertion, exposure to cold and damp, the loss 
of blood, as in the case of women after childbirth, or from menor- 
rhagia, prolonged lactation, and the changes due to the cessation of the 
menses. 



NEURAL HYPERESTHESIA. 841 

Another very common cause is syphilis, and there is reason to think 
that the gouty diathesis may also excite it. 

But, as Anstie ' remarks, it is after the powers of life begin to de- 
cline that the most formidable varieties of facial neuralgia are encoun- 
tered. Those forms which are attended with muscular spasm, consti- 
tuting the "tic douloureux" of the French, and another still more 
violent which Trousseau has designated " tic epileptiform," are almost 
peculiar to advanced life. The pain in these affections is atrocious, and 
is excited by the least muscular action in the face, by a touch, however 
light, or even by a breath of air. They are often accompanied lya 
hereditary tendency to insanity, and they eventually wear away the life 
of the miserable sufferer. 

Facial neuralgia may also result from tumors compressing the 
nerves, from thickening of the bones, or of the periosteum, causing 
narrowing of the foramina through which they pass, and from intersti- 
tial organic changes taking place in the nerve-trunks. 

The Diagnosis requires no special remarks, and the Prognosis de- 
pends upon the cause, and the ability to remove it. In general terms 
it may be stated that the malarial and syphilitic forms are usually 7 read- 
ily cured, while others are seldom thoroughly relieved. The intense 
varieties, coming on for the first time late in life, are absolutely incu- 
rable, and are verj 7 seldom capable of even being mitigated. 



CERYICO-OCCIPITAL NEUEALGIA. 

In this affection the pain is situated in the sensory branches of the 
first four cervical nerves, though the great occipital which arises from 
the second cervical is mainly the one affected. These nerves are dis- 
tributed to the occipital and posterior parietal regions, as well as to the 
neck and lower part of the cheek. The painful points are those at 
which the nerves become most superficial. 

The pain in cervico-occipital neuralgia, though severe, is not in gen- 
eral so intense as that of the facial variety. There is a tendency in 
the affection to extend so as to involve the inferior maxillary nerve, 
and, when the disease has lasted some time, a paroxysm rarely occurs 
without this nerve being implicated. After the acute stage of a par- 
oxysm has passed off, there remains a dull, heavy pain, which continues 
several days, and which is increased by the pressure of the clothing, by 
mental exertion, or by moving the head. 

The Causes are similar in general character to those of facial neu- 
ralgia, though cold is probably a still more powerful factor in the eti- 
ology. 

The Diagnosis and Prognosis call for no special remarks. 

1 Article " Neuralgia,^ in Reynolds's "System of Medicine," vol. ii., p 726. 



842 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 



CERVICO-BRACHIAL NEURALGIA. 

In this form the brachial plexus, the nerves which go to form it — 
the five lower cervical and first dorsal — and those which arise from it, 
are the seat of the affection. The pain may therefore be felt in the 
subclavicular region, along the whole length of the upper extremity, or 
in the situation of the mammary gland. The exact seat varies of course 
with the particular nerve affected. It is often accompanied by various 
sensations of numbness, and interferes more or less with the movements 
of the limb. The principal painful points are the axillary in the arm- 
pit, and corresponding to the brachial plexus, the scapular near the in- 
ferior angle of the scapula, the acromial in the angle between this pro- 
cess and the clavicle, the median cephalic in the bend of the elbow, the 
ulnar corresponding to the most superficial portion of the ulnar nerve 
at the back of the elbow-joint, and the radial at the point where the 
radial nerve becomes superficial at the lower part of the forearm. 

Among the Causes of cervico-brachial neuralgia, rheumatism, mala- 
ria, excessive muscular exertion, and injuries, are preeminent. It is not 
so frequently the result of malaria as the corresponding affection of the 
facial nerve. 

There is nothing special to be said relative to the Diagnosis and 

Prognosis. 

DORSO-INTERCOSTAL NEURALGIA. 

In this affection the dorsal and intercostal nerves are the seat of the 
pain. In the first case the disease is often regarded as rheumatic or 
muscular, and has received the popular name of lumbago ; in the latter 
it is often known as pleurodynia. Whether in the dorsal or intercostal 
form, the pain does not often occur in well-marked paroxysms, but is 
more or less Continuous in character, and is much increased by muscu- 
lar exertion. In the dorsal form, the mere act of straightening the 
back causes great suffering, and, in the intercostal, respiration is ex- 
ceedingly painful. 

The painful points are very numerous, and in general correspond to 
the situations where the nerves become most superficial. 

The association of intercostal neuralgia with herpes zoster of uni- 
lateral form is an interesting fact, and one which led to the recognition 
of other skin-diseases as being essentially nervous affections. 

The Causes of dorso-intercostal neuralgia are cold, rheumatism, 
malaria, exhaustion, and, in women, the depression of vital power, due 
to profuse menstruation or prolonged lactation. Anaemia, both in 
males and females, is also a common cause, however produced. 

The Diagnosis of the dorsal form is not a matter of difficulty ; the 
intercostal has, however, often been mistaken for pleurisy. The Prog- 
nosis is more favorable than in the other neuralgias described. 



NEURAL HYPERESTHESIA. 843 

Lumbo-abdominal and crural neuralgias are not very common. 
The latter is seldom a primary affection. 

Morbid Anatomy and Pathology. — The remarks which might be 
made under this head have already been expressed to some extent in 
the foregoing pages, and there is not much more that could be said 
without entering the domain of pure speculation. I may, however, 
state my opinion that neuralgia, not directly the result of some physi- 
cal cause interfering with the integrity of the nerve in which it is situ- 
ated, is almost invariably induced by a depressed state of the system. 
Its existence in such cases is evidence, therefore, of deficient physical 
stamina, and of the fact that the nervous system is not duly nourished. 
The remote factor may be malaria, syphilis, rheumatism, gout, or some 
other cause capable of lowering the vitality of the organism, and, 
as a consequence, that of the nerves. It is of course of the utmost 
importance with reference to the treatment, to ascertain whether 
there is, or is not, any such constitutional taint, but, whatever the 
result of our inquiries in this direction, that system of therapeutics 
is best which, in addition to special medication, embraces restorative 
means. 

Treatment. — The measures which it is proper to employ in neu- 
ralgia may be divided into two categories, the constitutional and the 
local. 

Among the constitutional remedies must be included those which 
are for the correction of any taint which may be present. If there is 
reason to suspect the existence of syphilis, iodide of potassium is an 
indispensable remedy, and should be given in large doses. It is also 
advisable in rheumatic neuralgias, especially of the cervico-occipital 
region. If malaria can be ascertained to have exerted an influence, 
quinine must be administered; and, indeed, it is safe to act upon the 
theory that this has been the cause, unless some other can be clearly 
made out. It must be recollected that malaria may give rise to neu- 
ralgia, especially in the facial nerve, without there having been any 
other manifestation of its toxic effect ; and that the affection is often 
cured by large doses of quinine, when the patient has not apparently 
been subjected to the malarious influence. Should there be no relief 
after three or four ten-grain doses of quinine, it should still not be de- 
cided that the disease is not of malarious origin, but the quinine should 
be given in still larger doses, as in Dr. Clinton Wagner's own case, in 
which fifty grains were taken in eight or ten hours. 1 If there is still no 
improvement, arsenic should be administered. I have seen many cases 
of supraorbital neuralgia, undoubtedly the result of miasmatic poison- 
ing, effectually cured by arsenic, when quinine had failed. From my 
own experience, I am very well convinced that it acts much more effica- 

1 " Proceedings of the New York Neurological Society," Psychological Journal, August, 
1874, p. 126. 



844 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

ciously when administered by hypodermic injection than by the stomach. 
Four drops of Fowler's solution, diluted with an equal quantity of 
water, should be given twice a day, and the quantity should be gradu- 
ally increased to eight or ten drops at a dose. Even in cases not 
malarious, arsenic will often be found to be a most valuable therapeutic 
agent. 

If a gouty diathesis is present, colchicum should be used ; and, if 
rheumatism be clearly made out, the blood should at once be rendered 
alkaline by liquor potassae. 

Whether any specific trouble be discovered or not, general ton- 
ics are always indicated ; among them cod-liver oil occupies the 
front rank, and iron is not far behind it in value ; strychnia is 
also very generally useful. Among constitutional remedies, ergot 
has proved of very decided benefit in my hands. It should be 
given in large doses, a drachm or more of the fluid extract three times 
a day. 

A full and nutritious diet is of great value in the treatment of 
neuralgia, as are likewise sunlight, and pure and fresh air. 

In addition to these purely constitutional measures, there are 
others which, though administered to act upon the system at large, 
are given for the purpose of arresting a paroxysm, or deadening sensi- 
bility, so as to prevent the pain being felt. The medicines embraced 
in this category are included among the stimulants, narcotics, and 
anaesthetics. 

Opium and its various preparations are preeminent as palliatives of 
the neuralgic paroxysm, and morphia stands first among them. It is 
most efficaciously administered hypodermically, in doses varying from 
one-sixth grain to half a grain, or even more in extreme cases. Great 
care should be exercised in its use, and the smaller quantity mentioned 
should not be exceeded except by regular gradations. It is immaterial 
in what part of the body the injection is made, so far as its influence 
over the pain is concerned. 

Among other medicines of this class are belladonna, or its alkaloid 
atropia, Indian hemp, aconite, gelseminum, bromide of potassium, hy- 
drate of chloral, hyoscyamus, conium, and some others of minor impor- 
tance. 

Of these, aconite is preferably employed in the form of Duquesnel's 
aconitia, and is often remarkably efficacious when all other means have 
failed. It should be used with great caution, and the doses be very 
gradually increased, till some decided evidence — numbness in the arras 
and legs, for instance — of its physiological action or the cessation of 
the pain be obtained. I usually give it in solution in dilute alcohol in 
the proportion of one grain to the ounce. Four minims of this, equal 
to the t |-q of a grain, are enough to begin with. In two hours a dose 
of five minims may be given, and so on, if necessary, up to ten minims, 



NEURAL HYPERESTHESIA. 845 

or ^ of a grain. Beyond this I have never ventured, and only once 
have I carried the dose to this point. The patient, a master brass-fin- 
isher, had suffered with intense left facial neuralgia, which had resisted 
every means that had been tried. When he first consulted me, I found 
some reason to suspect the existence of a syphilitic taint, and I treated 
him with large doses of iodide of potassium. This was in the early 
part of August, 1880. He gradually improved, and, while taking one 
hundred and eighty grain* a day, declared himself free from all pain. 
I continued the remedy for a couple of weeks longer, and then stopped 
its administration. But in a month's time he returned, with the pain 
as bad as ever. I again tried the iodide, with mercury in addition, but 
without the least effect, so far as mitigating his suffering was con- 
cerned. I then gave Duquesnel's aconitia in the way mentioned. At 
eight drops he began to experience relief, though there was a general 
burning sensation over the whole body, and great physical and mental 
prostration. I gave nine drops, and two hours afterward ten, with 
the effect of entirely stopping the pain ; and up to this time, four 
months having elapsed, there has been no relapse. Sometimes it fails. 
It did so notably in one of the worst cases of spasmodic facial neural- 
gia I ever saw, and which I brought before the American Xeurological 
Association at its meeting in June, 1880 ; but I have had several cases 
of a very severe type in which its effect was all that could be desired, 
and others in which it produced marked alleviation. Dr. R. F. AVeir ' 
has reported an interesting case of cure by its use. It is especially 
useful in facial neuralgia. Gelseminum is also a drug of undoubted 
power over neuralgia. Dowse Q expresses the opinion that its action is 
more specifically exercised upon the dental branches of the inferior 
maxillary nerve, and I am inclined to concur with him in this view. 

Of very great value are chloroform and ether, administered by 
inhalation, and the various forms of alcoholic liquors. It not unfre- 
quently happens that an attack of neuralgia can be at once aborted by 
an ounce or two of whiskey or brandy, especially in a person not 
habituated to their use. 

A somewhat different class of remedies for neuralgia are those 
which are either tonic to the nervous or general system, without, as 
quinine and arsenic, being antagonistic to malaria. Among these are 
strychnia, phosphorus, and iron. 

Of these, strychnia is, I think, most efficacious when administered 
hypodermically in doses of from the one forty-eighth grain to the one 
thirty-second grain twice daily ; or it may be given internally in 
somewhat larger doses three times a day. 

I have long used phosphorus in the treatment of neuralgia. I at 

1 Archives of Medicine, August, 1879. 

2 "Neuralgia; its Nature and Curative Treatment," London and New York, 1880, 
p. 33. 



846 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

one time extensively employed the phosphoretted oil, but more recently 
have substituted the phosphide of zinc, which, I think, is altogether a 
preferable form of administration. The formula given on page 68 
will fulfill every indication for phosphorus and strychnia. These two 
remedies are particularly beneficial in neuralgia occurring in persons 
who have exhausted the vital powers by dissipation and excesses of 
various kinds. 

Iron is especially valuable in cases of neuralgia due to, or accom- 
panied with, an anemic condition of the system. Anstie speaks highly 
of the tincture of the chloride, and ascribes to it a marked and direct 
influence upon the nervous centres different from that produced by 
other preparations of the mineral. It should be given in doses of 
thirty or forty minims, properly diluted in water, three times a day. 
While recognizing the benefit to be derived from this agent, I have 
generally preferred the sesquioxide in powder, which can be taken 
without injury to the teeth or probability of stomach derangement. 
Large doses — twenty to forty grains three times a day — should be 
employed. 

The chief local means of treatment consist of counter-irritation and 
the application of certain substances calculated to deaden the sensi- 
bility of the nerves. Under the former head come blisters and the 
various stimulating or irritating liniments, essential oils, solutions, and 
the actual cautery. Blisters should be applied along the course of the 
affected nerve. They are especially valuable in sciatica. Liniments 
are rarely of much service, and, moreover, they are dirty. Of the 
essential oils, that of a species of peppermint put up by the Japanese is 
sometimes of immediate service in supra-orbital neuralgia, as is also 
strong aqua ammoniae. The actual cautery often affords prompt relief, 
either when applied over the nerve or to some distant part of the body. 
In sciatica, Erb 1 speaks of the palliative effect of the red-hot iron 
applied to the external ear. As he very properly remarks, the fact 
that we cannot explain the rationale of its action is no reason why we 
should ridicule its use. 

Of sedative applications, the tincture of aconite, belladonna, opium, 
etc., are sometimes of service. Dr. Dowse, in the excellent little work 
already cited, speaks highly of a solution of chloral hydrate applied 
externally as being efficacious even when the same drug given inter- 
nally has failed to give relief. His method of using it is to make a 
solution in the proportion of one ounce of chloral to sixteen of water. 
This is then made hot. Three layers of lint dipped in this solution 
are next applied to the skin over the affected part, and over these three 
or four folds of flannel, previously soaked in very hot water and wrung 
as dry as possible. Over the whole a piece of India rubber sheeting 
is placed. The whole is then bound firmly to the surface, and left in 

1 Ziemssen's "Handbuch," Band xii., p. 162. 



NEURAL HYPERESTHESIA. 847 

position for six or eight hours. When removed, the skin should be 
painted with collodion or dusted with starch, and then covered with 
cotton wool. 

I have tried this process in one very severe case of crural neuralgia, 
and in one of cervico-occipital neuralgia, both of which were obstinate 
cases, with very gratifying success. 

Heat, either dry or moist, is of itself of service in most cases, and 
cold, in the form of ice, sometimes relieves neuralgic pain very 
promptly. 

But, above all local means, not only for relieving the pain of any 
particular paroxysm, but also for effecting a permanent cure, electricity 
stands first. I have employed it in every possible form, and am satis- 
fied that the primary galvanic current is the preferable agent. Indeed, 
I very much doubt if the faradaic current, unless in a few cases, when 
the wire-brush has been employed, has ever, in my experience, accom- 
plished any very decided benefit. In the employment of the galvanic 
current, the positive pole should be applied over the seat of the pain. 
The current should be feeble at first, but should be gradually increased, 
without interrupting it, up to the point of toleration. The application 
should be continuous for at least half an hour, and should be repeated 
every day for several weeks, and in extreme cases longer. I have 
cured a number of severe cases of nearly every kind of neuralgia by 
the aid of electricity when other means had entirely failed. I rarely, 
however, employ it without at the same time insisting on such consti- 
tutional treatment as the case seems to require. 

As to surgical operations on the affected nerves, either of section or 
excision of a portion of their continuity, the success which has hitherto 
followed them has not been such as, in my opinion, to warrant their 
repetition. 

But there are two other surgical means of treatment in certain neu- 
ralgic affections which have been recently introduced, and which are 
entitled to something more than a mere passing reference. These are 
"nerve-stretching" and "nerve-compression." 

The former has been practised mainly on the sciatic nerve, for the 
relief of sciatica — though it is applicable to other nerves. I have oper- 
ated on the sciatic nerve in this way five times, and with the result of 
affording immediate and, up to the present time, complete relief. I 
have always performed the operation on the nerve at about the junc- 
tion of the middle and lower thirds, that being the point at which it 
is more readily reached. I make an incision four or five inches in 
length through the skin and aponeurosis, and expose the nerve. I 
then pass under it an ivory paper-knife, and gradually lift the nerve 
from the bottom of the wound, stretching it to the extent of three or 
four inches, while making the traction as far as possible in a down- 
ward direction. In the last case, I put my index-finger under the 



848 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

nerve, and lifted it out of the thigh with much more ease and with 
less risk of injury than before, and this is certainly the preferable 
procedure. 

The operation is by no means a painful one ; in fact, there is no 
pain except that caused by the preliminary incision through the skin. 
I have in two of the cases omitted to use anaesthetics ; but in the 
others I employed the ether-spray, so as to abolish the sensibility of 
the skin. I prefer that the patient should be sensitive to pain while 
the stretching is being performed, as important information is derived 
from the sensations, the object being to carry the extension to the 
point of producing very decided numbness. 

I have never had any untoward accident follow the operation. For 
several days subsequently there have been numbness and paresis ; but 
these phenomena have gradually disappeared, and without being fol- 
lowed by a return of the pain. 

Compression, as a remedy for neuralgia, has been practised to a 
limited extent, but is, I think, worthy of more extended use. Dowse 1 
speaks of it as a "palliative mode of treatment, which certainly has 
some advantages ; " but I have in several cases carried it to a much 
greater extent than it has hitherto been employed. 

My first cases were two of neuralgia of the testis, 2 and in these I 
subjected the spermatic cord to pressure strong enough to break up 
the axis cylinder of the spermatic nerve, with the result in both in- 
stances of obtaining complete relief from the most agonizing suffering. 
In neither case has there been any return of the disease nor loss of 
genital power. I made use of an apparatus similar to a lemon-squeezer, 
the blades of which could be brought closely together by means of a 
screw, though in the first case a wooden test-tube-holder answered the 
purpose. Since the publication of these cases, I have employed com- 
pression in two cases of sciatica, using a tourniquet and an ivory ball 
for the purpose, but with only partial success, and, in one case of severe 
supra-orbital neuralgia, with complete relief. The cases in which com- 
pression is applicable are limited, of course, to those nerves which, by 
their situation, allow of strong force being exerted upon them, from 
the fact that they pass over bone, and to those which, like the spermatic 
nerve, admit of the whole tissue being compressed between two op- 
posing hard substances. 

1 Op. cit, p. 27. 

2 "Neuralgia of the Testis," St. Louis Courier of Medicine, May, 1880, and Neuro- 
logical Contributions, No. III., 1881. 



SYPHILIS OF THE PERIPHERAL NERVOUS SYSTEM. 849 

CHAPTER XL 

SYPE1LIS OF THE PERIPHERAL NERVOUS SYSTEM. 

The peripheral nerves are often the seat of various syphilitic le- 
sions. They maybe compressed even to the extent of complete destruc- 
tion by a syphilitic neoplasm developed in their tract. This compression 
may occasion a local neuritis with consecutive atrophic degeneration, 
and it is especially apt to be met with, in connection with the cranial 
nerves, at those points where they penetrate the dura mater, thickened 
by a syphilitic infiltration. Sometimes this leads to a slight compres- 
sion of the nerve, the sheath of which is thickened and the nerve itself 
softened ; and, again, to ansemia and subsequent atrophy. 

It may also happen that a gumma, developed in the vicinity of a 
nerve, reaches this last by direct growth. This is, above all, liable to 
occur with those nerves the sheath of which is not very thick, and par- 
ticularly for the chiasma of the optic nerve. Virchow, Von Graefe, 
and Heubner, have published cases of the kind. 

The peripheral nerves may also be the seat of primitive syphilitic 
lesions, and this to a considerable extent. They then lose their rounded 
form and white color, and present the appearance of reddish cords 
formed of connective or fibroid tissue. At other times they have been 
found of a lardaceous consistence, or rather swollen and infiltrated by 
a reddish or yellowish-gray substance. These alterations have, up to 
the present time, been exclusively observed in the cranial nerves. 

Finally, in the instances of certain neuralgic patients, peripheral 
paralyses have been observed which, persisting until the death of the 
individual, have presented, on the most thorough examination, no 
alteration in the corresponding nerves. Syphilitic lesions limited to 
a single nerve are always manifested by grave functional troubles 
of the organs supplied by the affected nerve, with integrity of neigh- 
boring organs. Generally these lesions concern the oculo-motor nerve. 
Ptosis is then observed before the movements of the globe of the eye 
are affected. Later are developed external strabismus, exophthalmia, 
and a considerable dilatation of the pupil. 

When the syphilitic lesion affects the branches of the facial, the 
ordinary symptoms of paralysis of this nerve are observed. When it 
is limited to the abducens, there are internal strabismus and diplopia. 
Paralysis of the muscles of mastication of one side has been noticed, 
consecutive to a syphilitic alteration of the motor branch of the fifth 
nerve of the corresponding side. 

Peripheral motor paralyses of syphilitic origin are accompanied: with 

abolition of the electric excitability of the branches of the affected nerves 

(Ziemssen), and with atrophy of the corresponding muscles (Heubner). 
55 



850 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. 

Syphilitic lesions may concern the sensory portion of the trifacial, 
and then a trifacial neuralgia is developed, the origin of which is re- 
vealed by its nocturnal exacerbations. Hypersesthesia sooner or later 
is replaced by anaesthesia. 

Cases cf amblyopia and of amaurosis, yielding to the action of spe- 
cific medication, and evidently due to syphilitic lesions of the optic nerve, 
have been published. These lesions may also be manifested by hemiopia. 

And here and there in medical literature cases are found recorded 
of neuralgia affecting various parts of the body, and which have been 
promptly cured by anti-syphilitic treatment. 

Several cases of syphilitic anaemia have come under my observation, 
in which there was no reason for suspecting a central lesion, and which 
were promptly cured by the specific treatment recommended in other 
parts of this work. Cases of syphilitic deafness, due to alterations of 
the auditory nerve of one or both sides, are by no means infrequently 
met with, and, unless taken very early in their development, by the 
most decided anti-syphilitic treatment, are apt to prove intractable. 

Aphonia, due to paralysis of the laryngeal muscles, from syphilitic 
alterations of the communicating branch of the spinal accessory nerve 
or the recurrent laryngeal nerves, is not a very uncommon occurrence, 
and is usually, if subjected to treatment before the excitability of the 
muscles is lost, a not obstinate affection. 

In all cases of syphilitic paralysis, in addition to the specific treat- 
ment imperatively demanded, electricity should always, if possible, be 
employed. I mention this last fact particularly, because I am led to 
believe the idea is more or less prevalent, that such paralyses require 
no other treatment than iodide of potassium and mercury. I have re- 
peatedly found in cases of facial paralysis, clearly syphilitic in charac- 
ter, that the electric contractility of the muscles to the faradaic cur- 
rent was entirely abolished, and that the galvanic current of strong 
tension was necessary to excite them to action. 



SECTION V. 

DISEASES OF THE SYMPATHETIC 
NERVOUS SYSTEM. 1 



CHAPTER I. 

PATHOLOGY OF THE CERVICAL SYMPATHETIC. 

Whatever idea we may form of the relations of the great sym- 
pathetic with the cerebro-spinal axis, and of the nature of the nervous 
functions which devolve upon it, it is incontestable that the nerve ex- 
ercises an immediate influence over the circulation, calorification, the 
secretions, and the nutrition of the organs to which it is distributed, 
and over the elements comprised in these organs. The well-known 
experiment of Claude Bernard, which consists in dividing the great 
cervical sympathetic, is quite adequate to exhibit these several influ- 
ences. As a consequence of such a section there result : 

1. A very apparent dilatation of the vessels of the face and of the 
ear of the corresponding side, and which amounts to a well-marked 
congestion of these parts. Nothnagel has been able to convince himself, 
by direct observation, that these vascular troubles affect also the mem- 
branes and the encephalon of the corresponding side. 

This dilatation and congestion has been attributed to a paralysis of 
those vaso-motor fibres of the sympathetic which give tone to the ves- 
sels. If, in fact, a continuous galvanic current be passed through the 
peripheral segment of the divided nerve, we see the vessels resume 
their normal calibre, and at the same time the phenomena of conges- 
tion disappear. 

2. An elevation of local temperature, especially manifested in the 
natural cavities (auditory canal, nostril, mouth), on the side with the 

1 Although there is, in my opinion, scarcely sufficient data relative to the diseases of the 
sympathetic nervous system to warrant the subject being fully considered in a systematic 
treatise like the present, I have thought it well to incorporate Dr. Labadie-Lagrave's excel- 
lent synopsis, which he prepared as an appendix to his French translation of this work. 



852 DISEASES OF THE SYMPATHETIC NERVOUS SYSTEM. 

section. The difference of temperature between one side and the other 
may reach as much as 1*5° Centigrade. 

This local elevation of temperature is in part the result of the vas- 
cular congestion determined by the division of the vaso-motor nerves. 
We know that the temperature of the peripheral organs is, in general, 
more elevated when an increased quantity of blood circulates through 
them. But, as this local rise of temperature remains after all trace of 
vascular congestion has disappeared, it has been supposed that the 
vaso-motor nerves exercised a direct influence over the function of 
calorification of the tissues ; that the vaso-motor fibres moderate to a 
certain extent the nutritive changes of the organs to which they are 
distributed, and that, moreover, their paralysis causes an increase in 
local organic combustion, and consequently augmented temperature. 
This explanation seems to be all the more reasonable, from the fact that, 
at a later period, the local elevation of temperature is succeeded by a 
burning which coincides with a local denutrition of the tissues, as, for 
instance, hemiatrophy of the face. At the same time, in this second 
period, the paralyzed side does not perspire, or, if it does, perspires 
less in amount and less frequently than the sound side (Nicati), while 
during the period immediately after section of the great sympathetic 
we observe : 

3. A decided diaphoresis with epiphora, very exactly limited to 
the half of the face on the same side as the section. 

4. Contraction of the pupil and of the palpebral opening, with re- 
traction of the globe of the eye on the same side as the section. The 
contraction of the pupil, consequent on section of the great cervical 
sympathetic, is easily explained if we admit that this nerve has control 
of the radiating fibres of the iris. When these fibres are paralyzed, 
the irian sphincter, no longer having its action resisted, contracts, and 
the pupil is diminished in size. The narrowing of the palpebral open- 
ing and the retraction of the eyeball have been attributed to paralysis 
of the orbital muscle of Miiller innervated by the sympathetic, and 
which has for its function the counteraction of the straight and oblique 
muscles of the eye, and of preventing these muscles from drawing the 
globe backward. 

In exciting the cervical sympathetic with the galvanic current, for 
example, we observe a certain number of phenomena, the reverse of 
those which result from its section. The pupil is dilated, the eyelids 
are widely opened, and the eyeball is projected forward ; the vessels 
are contracted and the circulation restricted, at the same time that the 
temperature is diminished in the corresponding half of the face. The 
sensibility is diminished on the same side, the cornea and conjunc- 
tiva become dry, and the convulsions caused by strychnia are less pro- 
nounced than on the opposite side (Waller, Budge, Claude Bernard, 
and Brown-Sequard). 



PATHOLOGY OF THE NERVOUS SYMPATHETIC. 853 

These experimental results accord perfectly with those obtained by 
clinical observation in man. In a certain number of cases of trau- 
matic lesions of the cervical sympathetic, published during the last 
twenty years, there have been mentioned with variable frequency the 
different oculo-pupillary and vaso-motor troubles that can be produced 
by electrizing the sympathetic. 

Fourteen cases of functional troubles of the cervical sympathetic, 
consecutive to traumatic lesions of this nerve, are then given on the 
authority of Weir Mitchell, Verneuil, Seeligmuller, Barwinkel, and 
others, and eleven cases, from Panas, Poiteau, Eulenburg, and others, 
of similar derangements from the presence of tumors in the course of 
the nerve. 

Spontaneous paralysis of the cervical sympathetic is also known 
to be produced, in appearance at least, although not very often. Six 
cases cited from Barwinkel, and one from Nicati, are given in illustra- 
tion, in all of which there were vaso-motor and oculo-pupillary troubles, 
limited to one side, and in all respects similar to those following sec- 
tion of the nerve. 

Besides these, there may be functional troubles of the cervical sym- 
pathetic, as consequences of spontaneous or traumatic lesions of the 
nervous centres. Barwinkel gives the case of a man who, having the 
symptoms of bulbar sclerosis, presented also a certain number of phe- 
nomena peculiar to paralysis of the cervical sympathetic, and Seelig- 
muller that of a woman w^ho had like symptoms, in conjunction with 
cerebral haemorrhage. 

In 1869 M. Rendu collected, in a very interesting memoir, a cer- 
tain number of cases, in which- traumatic lesions of the marrow were 
complicated with functional troubles of the cervical sympathetic, some 
attributable to paralysis, and others to excitation of the nerve. As in 
the instances we have cited, oculo-pupillary derangements were most 
frequently observed. Of eighteen cases referred to by him (fractures, 
luxations, and wounds with cutting instruments), implicating the cer- 
vical sympathetic, the pupil was contracted on the side of the lesion 
fourteen times. Sometimes there was noted a narrowing of the palpe- 
bral opening, with injection of the conjunctiva, the face, and the ear, 
and elevation of temperature in the same parts. These vaso-motor 
troubles, complicating contraction of the pupil and of the palpebral 
opening, were particularly marked in a case cited by M. Rendu from 
M. Brown-Sequard. 1 

All these facts sufficiently demonstrate that the superior portion of 
the spinal axis exercises over ocular innervation, and the circulation 
and the calorification of the cephalic extremity, an influence analogous 
to that of the great cervical sympathetic. They also go to show that 

1 Archives generates de Medecine, tome xiv., 1869, p. 286. 



854 DISEASES OF THE SYMPATHETIC NERVOUS SYSTEM. 

the cervical sympathetic draws a great part of its nervous action from 
the superior segment of the spinal cord. 

A like inference must also be drawn from the fact that in locomo- 
tor ataxia there are similar disturbances in the movements of the pupils 
— disturbances which, as we have already seen, are among the earliest 
symptoms of the spinal affection. 

CONCLUSIONS. 

From a consideration of the preceding facts, we see that of four- 
teen cases of traumatic lesion of the region of the neck, in which there 
were also functional troubles of the cervical sympathetic, ten were of 
the form of paralysis, while in four only were the symptoms indicative 
of irritation. In compression of the cervical sympathetic by tumors, 
of eleven cases, eight were manifested by paralysis, and three only by 
irritation. And in instances of the compression of the sympathetic by 
intra-thoracic tumors, functional troubles affected the cervical portion 
of the nerve, and they were always of a paralytic character. 

The troubles consist, for the most part, of oculo-pupillary phenom- 
ena — constriction or dilatation of the pupil and of the palpebral open- 
ing. More rarely circulatory and calorific troubles (such as congestion 
with local elevation of temperature in the case of paralysis of the 
great sympathetic, paleness of the countenance, with lowering of tem- 
perature in the case of irritation of the nerve), and derangement of the 
secretions, are noted. In one case, the compression of the sympathetic 
by one of the lobes of an hypertrophied thyroid gland caused no other 
symptom than an increased secretion of sweat. 

In a certain number of cases of traumatic lesions of the cervical 
sympathetic, oculo-pupillary and vaso-motor troubles are complicated 
with an atrophy of the half of the face on the same side as the lesion. 
M. Nicati is therefore wrong, in his rather theoretical description of 
the course of the morbid phenomena in cases of paralysis of the great 
sympathetic, in considering hemiatrophy as a symptom of the late 
period of the disorder. In Case III., hemiatrophy was one of the phe- 
nomena of irritation of the sympathetic, along with mydriasis, paleness 
of the corresponding side of the face, and depression of temperature 
of the external auditory canal ; and, in Case VII., hemiatrophy was 
developed a short time after the accident which caused the paralysis of 
the sympathetic. 

We also notice that, in a case reported by Willebrand (XVII.), the 
use of iodine preparations caused, not only the disappearance of a sub- 
clavicular strumous tumor, but also the paralysis of the cervical sym- 
pathetic, which had justly been attributed to the compression of the 
nerve by the growth. M. Verneuil has seen the dilated pupil of an 
individual who was the subject. of a cervical abscess resume its normal 
diameter when the abscess was opened and emptied of its contents. 



NEUROSES OF THE CERVICAL SYMPATHETIC. 855 

A like fact has come under my own observation. It occurred in a. 
lady upon whom I had operated for a multilocular cystic tumor of the 
neck, immediately over the sympathetic nerve. After the excision, a 
large cavity was left, which was filled with lint for the purpose of 
arresting the oozing of blood. In a short time symptoms of irritation 
of the pneumogastric and sympathetic nerves were developed. These 
consisted of vomiting, irregular respiration, and great disturbance of 
the heart's action (pneumogastric), and dilatation of the pupil and 
paleness of the face on the side of the lesion (sympathetic). On re- 
moving the pledgets of lint, both series of phenomena at once ceased. 



CHAPTER II. 

NEUROSES OF THE CERVICAL SYMPATHETIC. 
MIGRAINE, OR HEMICRANIA. 

Lately certain neuroses have been regarded as functional troubles 
of the sympathetic nerve. Sometimes they are apparently the result of 
an irritative action, and, again, of a paralytic state of various parts of 
this nerve. 

By migraine, or hemicrania, we understand a painful paroxysmal 
affection, limited to one half of the head, and whichis accompanied by 
oculo-pupillary, circulatory, and calorific, disturbances, which serve to 
distinguish the painful crises in question from supra-orbital, temporal, 
or occipital neuralgias, with which they are often, nevertheless, con- 
founded. 

The attacks are, in general, of irregular succession, and, in the inter- 
vals between them, the patient is apparently entirely well. Usually, 
the approach of a paroxysm is announced by prodromatic phenomena. 
The patient is irritable, and indisposed for mental labor. Among other 
premonitory signs may be mentioned yawning, noises in the ears, the 
presence of dark specks (scotoma) in the visual field, sneezing, a feeling 
of constriction in the side of the head to be attacked, and, above all, 
nausea. 

The hemicranial pain generally attains to its highest point in a 
gradual manner. More frequently it is seated in the left than in the 
right side of the head, but it may in the same patient attack each side 
alternately. The pain, instead of being lancinating or boring, as in 
the case of neuralgia, is rather constricting, and covers a great area 
Ordinarily, it is sharpest in the frontal, occipital, or parietal region. 
There are no painful points, as in neuralgia. Often, however, pressure 
over a circumscribed part of the parietal region causes an exacerbation 



856 DISEASES OF THE SYMPATHETIC NERVOUS SYSTEM. 

of the hypersensitiveness to pain. Ordinarily, also, pressure over the 
superior or middle cervical ganglion is painful. More rarely, a like 
effect follows strong pressure made over the spinous processes of the 
cervical aud first dorsaj vertebrae. We may state, also, that Dr. Berger 
has shown with the sesthesiometer that a certain degree of tactile hyper- 
esthesia exists on the half of the face corresponding with the affected 
side. 

In addition to the pain, we have to call attention to other prominent 
symptoms which are habitually present. These are nausea and vomit- 
ing, hallucinations, such as noises in the ears, circles of fire in the eye- 
sight, and a disagreeable taste in the mouth. Then come, also, oculo- 
pupillary and vaso-motor troubles, which, according to Eulenburg, may 
be of two distinct clinical types : 

1. Sometimes it is observed that, during the duration of the parox- 
ysm, the pupil on the affected side is manifestly dilated, at the same 
time that the ball of the eye is retracted to the bottom of the orbital 
cavity. The corresponding half of the face and the ear of the same 
side are of an extreme paleness, and the temporal artery is contracted 
and forms a hard cord, much less prominent than that of the oppo- 
site side. The temperature of the external auditory canal is lower 
than that of the same side — 0.4° to 0.6° C. It is also a matter of 
demonstration that every cause capable of diminishing the flow of 
blood to the painful half of the head augments the suffering. This 
is especially shown if the carotid artery of the affected side be com- 
pressed. If the opposite carotid be compressed, the pain is lessened. 

Toward the end of the paroxysm, when the hemicranial pain is on 
the point of beginning to disappear, the pupil contracts, the pallor of 
the face and of the ear of the painful side is replaced by a state of 
congestion, with sensation of heat, elevation of local temperature, injec- 
tion of the conjunctiva, epiphora, and acceleration of pulse. The 
painful crisis very often ends by the appearance of a profuse sweat, an 
abundant flow of urine, or by a diarrhceal flux. As is readily per- 
ceived, the symptoms of this form of hemicrania recall to our minds 
the results due to traumatic or experimental excitation of the cervical 
sympathetic. It is for this reason that it has been proposed to give to 
this clinical form the name spasmodic or sympathicotonic hemicrania. 

2. At other times the oculo-pupillary and vaso-motor disturbances 
are presented with characteristics absolutely the reverse of those to 
which we have called attention. During" the duration of the paroxysm 
the pupil is contracted, as is also the palpebral opening, and the upper 
eyelid droops. The face and ear of the affected side are injected, and 
the temperature of the external auditory canal exceeds by 0.2° to 0.4° 
C. that of the unaffected side. The dilated temporal artery beats with 
force, the pulse is often rendered slower, and compression of the 
carotid artery of the painful side diminishes the pain. Toward the 






NEUROSES OF TEE CERVICAL SYMPATHETIC. 857 

end of the paroxysm these symptoms generally change. This form of 
hemicrania has been called angio-paralytic or neuro-paralytic, for the 
reason that the symptoms which constitute a paroxysm are exactly 
like those which are observed on section of the great cervical sympa- 
thetic. 

Cases have been reported in which the paroxysms have in the same 
patient alternated in character — the angio-paralytic appearing at one 
time, and the angio-spastic at another. At other times, the hemicranial 
pain constitutes the only phenomenon of the accession, the vaso-motor 
and oculo-pupillary troubles being entirely absent. 

As we have already remarked, the paroxysms of angio-spastic and 
angio-paralytic hemicrania realize with the utmost exactness the mor- 
bid picture observed as the consequence of excitation or section of the 
cervical sympathetic nerve. On this account, certain authors, and par- 
ticularly Du Bois-Reymond, and Eulenburg, in Germany, have not hesi- 
tated to invoke the mechanism in question in the pathogeny of this 
painful neurosis. Angio-spastic hemicrania should, accordingly, have 
its point of departure in a periodical irritation of the great sympathetic 
or of the superior cervical ganglion ; while a paralytic condition of 
these organs is considered to be the cause of angio-paralytic hemicrania. 

But this theory has met with opposition. Thus Drs. Brown-Sequard 
and Althaus have insisted that vascular spasm of one half of the ence- 
phalic extremity would naturally produce anaemia of the correspond- 
ing cerebral hemisphere, and that such a disturbance of the circulation 
would cause epileptiform convulsions of the opposite half of the body. 
But Eulenburg remarks with much reason that electrization of the 
central extremity of the diseased cervical sympathetic produces a vas- 
cular spasm on the corresponding side of the head and of the encepha- 
lon, and at the same time the oculo-pupillary and vaso-motor troubles 
described above. Moreover, the like results are obtained in cases of 
traumatic irritation of the great cervical sympathetic. Finally, this 
author asks whether irritation of the nerve in question does not rather 
induce a partial ischaemia, limited to certain regions of the encepha- 
lon, than generalized anaemia extending over the half of this organ. 

But if the spasm or relaxation of the vessels of a half of the cephal- 
ic extremity, when compared with the like conditions obtained by ex- 
perimental physiology, enables us to account for the vaso-motor and 
oculo-pupillary disturbances observed in the course of one or the other 
form of hemicrania, how are we to explain the principal symptom, 
pain ? Are we to place the seat in the nervous ramifications, which the 
trigeminus supplies to the dura mater, or in those which the same 
nerve, as well as the sympathetic, sends to the vascular network of 
the pia mater ? According to Du Bois-Reymond, the pain in the 
angio-spastic form has no other cause than the tetanic contraction 
of the non-striated fibres of the vascular walls. It has its analogue 



858 DISEASES OF THE SYMPATHETIC NERVOUS SYSTEM. 

in cases of contractions of the muscles of the calf of the leg, of the 
uterus, and of the intestinal walls, either one of which produces pain- 
ful sensations. This explanation, which does not lack ingenuity, can 
only at most be applied to one of the forms of hemicrania. 

Eulenburg has proposed, in place of this theory, one of his own, 
which he thinks is applicable to all cases. In his opinion, hemicranial 
pain has its point of departure in a disturbance of the circulation, 
either as anaemia or hyperemia of the affected cerebral hemisphere. 
This circulatory trouble acts as a veritable irritant to the sensory 
nerves of the skin, the scalp, and the meninges, and thus develops the 
painful paroxysms of migraine. 

By some pathologists, and notably Anstie ' and Clifford All butt, 2 
migraine has been regarded as a neuralgic affection of the ophthal- 
mic branch of the fifth nerve, the latter, however, contending for the 
simultaneous existence of cephalic and abdominal complications. This 
view must, I think, give way to that which ascribes the main causative 
influence to derangement of the sympathetic nerve. 

But my own experience does not lead me to the extent of accept- 
ing the theory of Du Bois-Reymond, that migraine is always the re- 
sult of a contraction of the vessels — a tetanus, in fact, of the muscular 
coat ; nor to that of Mollendorf, 3 according to which it is always due 
to a relaxation of the vessels and an increased flow of blood to the 
brain. I am quite sure, with Eulenburg and Gutman, 4 that there are 
cases under each of these heads, a view which is also held by Berger. 5 
Clinical experience is so decidedly in favor of this latter theory, that it 
appears impossible to resist the conclusion to which it leads, for we 
find in practice that those agents which diminish the tone of the ar- 
teries cure some cases and aggravate others, while those remedies 
which increase the arterial tension are sometimes efficacious and again 
injurious. The importance, therefore, of making an exact diagnosis 
of the forms of hemicrania with which we have to deal cannot be 
over-estimated ; but, with this end in view, net only should inquiries 
be instituted relative to the appearance of the face, as regards pallor or 
redness and temperature, the oculo-pupillary phenomena, and the ef- 
fects of such remedies as may previously have been given, but oph- 
thalmoscopic examination should be made, if possible, at different 
times throughout the duration of the paroxysm. Mollendorf observed 
that, in the eye of the affected side, the fundus was of a bright scar- 

1 "Xeuralgia and the Diseases that resemble it," New York, 1872, p. 154. 

2 " On Migraine," Practitioner, January, 1873. 

3 "Tiber Hemicranie," Yirchow''s Archiv, Band xli., p. 385. 

4 "Physiology and Pathology of the Sympathetic System of Xerves," translated by 
Napier, London, 1879, p. 65. 

5 "Zur Pathogenesc der Hemicranie," Virchoic's Archiv, Band lix, H. 3 and 4, 1 S74 ; 
also, translation by Dr. G-radle, Chicago Journal of Xervous and Mental Diseases, July, 
1S74, p. 296, et scq. 



NEUROSES OF THE CERVICAL SYMPATHETIC. 859 

let color, while in that of the opposite side it remained of its normal 
brownish-red hue. I have not only frequently noticed this appear- 
ance, but in other cases have witnessed a pallor of the fundus of the 
eye on the affected side, only to be explained on the hypothesis of a 
diminished amount of blood being in the encephalic arteries on that 
side. Information of important diagnostic value can also be obtained 
by observing the effect of pressure on the carotid artery during the 
period of the seizure. In the anaemic form the procedure causes an 
aggravation of the suffering, while in the hypersemic it produces prompt 
mitigation of the pain and other attendant phenomena. 

Treatment. — The vaso-motor theory of migraine has been in part 
our guide to the treatment, and the efficacy of the means employed has 
given us data for successful management, which, though based on em- 
piricism, are of great value. 

Thus, it was reasonable to conclude, a priori, that the functional 
trouble of the great sympathetic could be alleviated by the electric 
current, and experience has established the wisdom of this deduction. 
J. Benedict, Frommhold, Freber, Rosenthal, and Althaus, as cited by 
Eulenburg, 1 have published cases of migraine treated with success by 
galvanization of the great sympathetic. Hoist, 2 basing his procedure 
on the polar theory of Brenner, advises the following method for the 
galvanization of the cervical sympathetic : In the angio-spastic form 
of migraine, in which it is necessary to moderate the irritability of the 
nerve, a current from ten to fifteen elements should be employed, 
the positive pole being applied over the sympathetic, and the negative 
held in the hand of the same side. Each seance should last for from 
two to three minutes. In the angio-paralytic form, the negative pole 
should be applied over the course of the nerve. To obtain a more 
energetic action on the nerve, the current should be frequently inter- 
rupted, or even reversed. 

In point of fact, however, according to my experience, it is a mat- 
ter of no consequence what the direction of the current is in either 
form of the disease. One pole should be applied over the nerve in the 
neck, and the other placed, preferably, on the pit of the stomach, and 
the action continued for from two to five minutes. 

Frommhold, 3 however, advises the use of the faradic current in the 
affection, and Freber 4 agrees with him in this practice. In my experi- 
ence, it cannot be compared in efficacy to the galvanic current, and, 
indeed, I have often found it to aggravate the pain. When it is used, 

1 Ziemssen's " Handbucli der speciallen Pathologie und Therapie," Band XII., p. 28 ; 
also, " Physiology and Pathology of the Sympathetic System of Nerves," by Eulenburg 
and Gutman, Napier's translation, London, 1879, p. Y0. 

2 "Dorpater medic. Zeitschrift," Band II., 1871, p. 261. 

3 " Die Migraine und ihre Haudlung durch Electricitat," Pesth, 

4 " Compendium der Electrotherapie," Wien, '1869. 



800 DISEASES OF THE SYMPATHETIC NERVOUS SYSTEM. 

the interruptions should be very rapid, and the intensity as great as 
the patient can endure. 

During the intervals between the attacks, galvanism should still be 
employed as a remedial agent, with the view of altering, if possible, 
the tendency to the occurrence of paroxysms ; but it is then not the 
chief therapeutical agent. Indeed, I am not disposed to think that it 
is ever entitled to this distinction. 

In my own practice, during the existence of the paroxysm, I first 
endeavor to ascertain the character of the seizure. If it is of the angio- 
spastic variety, that is, the form in which the calibre of the blood- 
vessels is diminished, I administer a large dose of morphia, say the 
quarter or third of a grain, by hypodermic injection, and at the same 
time cause the patient to take repeated inhalations of the nitrite of 
amyl. Latterly, I have sometimes, for the nitrite of amyl by inhala- 
tion, substituted the internal administration of this drug in doses of 
from one to four or five drops, or of glonoine in doses of the one hun- 
dredth of a grain. 

If there is reason to suspect the influence of malaria in the produc- 
tion of the disease, I give a large dose (from twenty to forty grains) 
of the sulphate of quinine, instead of the morphia and other substances 
mentioned. Experiments which I performed, in conjunction with 
Roosa, 1 show that under the action of this agent the amount of blood in 
the brain is increased. As these experiments bear directly on the ques- 
tion at issue, I may be permitted to quote them here. It is well known 
that the obvious phenomena which result from a large dose of quinia are 
such as indicate an increased flow of blood to the brain. The redness 
of the face, the injection of the conjunctiva?, the noises in the ears, the 
sensation of distention or fullness or constriction felt in the head, are 
all so many indications of cerebral hyperemia. Still, I was desirous 
of settling the matter by direct experiment and the employment of 
those instruments of precision which the progress of science has put at 
our disposal. 

With this object I resolved to take quinine myself, and to have 
my friend Dr. Roosa, whose abilities as an ophthalmologist and aurist 
are indisputable, examine the fundus of the eye and the tympanum 
before the ingestion of the quinine and during the continuance of its 
effects. 

The experiment was made on the evening of May 7th, and I sub- 
join his report in his own words : 

" Vision normal — To 

Refraction emmetropic. 

Pulse 90 



1 " The Influence of the Disulphate of Quinine over the Intra-Cranial Circulation," 
Psychological and Medico-Legal Journal, October, 18*74. 



NEUROSES OF THE CERVICAL SYMPATHETIC. 861 

" Ocular conjunctivae white, decidedly free from hyperemia. Pal- 
pebrae congested at outer and inner canthus. Has no tinnitus aurium. 
Membrana tympani entirely free from evidence of vessels. No conges- 
tion along handle of malleus. 

" Ophthalmoscopic examination of both eyes reveals a remarkably 
clear optic papilla on both sides. Arteries and veins, vertical and hori- 
zontal vessels, clearly cut, and whole papilla sharply defined, rather 
paler than congested. 

"Took grs. x. sulphate of quinine at 8.30 p. m. At 9 p. m. ocular 
conjunctiva is congested at outer and inner canthus. Palpebral con- 
junctiva markedly congested over whole surface. No change in optic 
papillae or in drum-heads. 

"9.15. Surface of optic papillae pinkish ; arterial vessels seem more 
distinct ; no change in appearance of drum-heads ; no tinnitus aurium. 

" 10. Head feels full ; left ear rings ; auricles burn ; face is de- 
cidedly flushed ; auricles red, especially lobe of right, where there is a 
localized congestion that is so marked as to resemble an ecchymosis. 
There is now a vessel along each malleus ; optic papillae are pinkish. 
Pulse 84 and fuller. 

" 10.30. Right drum-head is very much injected along handle of 
malleus and upper margin. Left less so, but yet injected. Both 
papillae very pink, left more so than right. Face flushed, eyes suffused, 
ocular conjunctiva decidedly congested. Slight headache ; tinnitus in 
both ears. 

" 11. Redness of auricles diminishing, especially the circumscribed 
spot on the lobe of left one ; face still flushed ; tinnitus continues ; no 
headache ; feels exhilarated. Drum-heads still injected along malleus ; 
not more so, however, rather less ; optic papillae have a decidedly pink- 
ish hue ; no more lateral vessels seen, however ; right is especially 
pink. Tinnitus still continues ; vision normal. No further observa- 
tions were made." 

That the phenomena indicated cerebral hyperaemia is self-evident, 
and therefore no further remarks on the point are necessary. 

But it was possible to determine the question with even greater 
certainty. 

I therefore trephined a medium-sized dog, and screwed a cephalo- 
haemometer into the opening in the skull made by the trephine, so that 
the fluid in the glass tube stood at zero. 

I then introduced into the cellular tissue of the abdomen ten grains 
of sulphate of quinine, dissolved in water acidulated with sulphuric 
acid. This was done at 3.30 o'clock p. m. 

At 3.35 the fluid had risen one degree on the scale (= T V inch). 
It continued to rise gradually but steadily, till at 4.10 it had passed 
over ten degrees (=1 inch of the tube). At 4.30, one hour after the 
injection of the quinine, the fluid was at -f 15°. It continued at this 



862 DISEASES OF TIIE SYMPATHETIC NERVOUS SYSTEM. 

point till 5.10, when it began to fall, and at 8.15 was at zero. It re- 
mained stationary for over an hour, at no time falling to the minus 
division of the scale. 

The stage of excitement scarcely lasted fifteen minutes. It was 
succeeded by a state of sedation during which the salivation was 
excessive, and the animal appeared very much as if under the influence 
of a full dose of alcohol. As the normal condition of the dog was 
regained, the fluid fell in the tube, and reached the zero almost simul- 
taneously with the disappearance of the symptoms of intoxication. 

I repeated the experiment on different days with variable doses of 
quinine — from two grains to fifteen — in all, four times, and invariably 
with the result of a steady rise of the fluid in the tube as the effect of 
the drug increased, and its fall to the zero as the influence wore off. 
At no time did the fluid reach a lower point than that at which it 
stood before the administration of the quinine. 

I think the several experiments detailed in this memoir show con- 
clusively that the influence of the sulphate of quinine over the intra- 
cranial circulation is that of causing hyperaemia and congestion. 

So far as I am aware, there are no experiments on record such as 
I have described, and the theory that the sulphate of quinine produces 
cerebral ana3mia is one not based on fact, but solely on the interpreta- 
tion of certain phenomena to accord with a previously formed hypothe- 
sis of its physiological action. 

I think, therefore, that quinia may properly be regarded as an 
antagonist to the tetanic condition existing in the angio-spastic form 
of migraine — in addition to its anti-periodic virtue. Experience shows 
that the effect is almost always an abrupt cutting short of the parox- 
ysm, especially if the nitrite of amyl be inhaled repeatedly, and to the 
extent of obtaining the full physiological effect of the drug. 

In this angio-spastic form of migraine, the treatment in the intervals 
between the paroxysms should consist of the administration of some 
one of the bromides (sodium, potassium, calcium, or ammonium) in 
doses of at least fifteen grains three times a day ; for, although the 
influence of these remedies is to diminish the ampunt of blood in the 
brain, they are antagonistic to all forms of muscular spasm. Either 
one of those mentioned may be advantageously given, in combination 
with pepsin and charcoal, as recommended under the head of " cere- 
bral congestion." If this method of treatment be followed out for 
two or three months with firmness and persistency, a cure may reason- 
ably be expected in the great majority of cases. 

The treatment during the paroxysm in the angio-paralytic form 
should be in many respects the very opposite of that proper for the 
angio-spastic variety. So far, however, as the use of electricity goes, 
no change is necessary, and a seizure may sometimes be cut short by 
the galvanic current, from ten to fifteen elements. 



PATHOLOGY OF THE THORACIC SYMPATHETIC. 863 

Cold to the nape of the neck is also of great value, and compression 
of the carotid on the affected side is a ready and prompt means of 
aborting a seizure in many cases. It should be continued in some 
instances for an hour, or even longer, and then the pressure should be 
very gradually removed. 

For internal medication, a large dose — thirty or forty grains — of 
guarana or paullinia sometimes acts like a charm, as does also strong 
coffee, or, better still, caffeine. In some instances strong tea will 
arrest a paroxysm when coffee has entirely failed. 

Phenacetine in doses of from ten to fifteen grains, which can be 
repeated in an hour if necessary, often affords prompt relief. Anti- 
pyrine and antifebrine are also efficacious, but should always be used cau- 
tiously. These remedies not only frequently fail to relieve the angio- 
spastic form of the disease, but, on the contrary, often aggravate it. 

But it is not wise to rely entirely on any one of the measures. 
Cold, compression of the carotid, and galvanism, should be employed 
at the same time, and some one of the internal remedies administered, 
to be followed by another, if it is not quickly efficacious. 

After the paroxysm is over, the real curative treatment should be 
begun, and this should, as in the other form, consist of the bromides, 
but in combination with ergot. I usually give the mixture just recom- 
mended, substituting the fluid extract of ergot wholly or in part for the 
water, and continuing the treatment for several months. It is rare 
that a case resists this form of management. 

And, in both varieties, attention should be paid to the hygiene of 
the patient. The diet should be simple but nutritious. It is an un- 
doubted fact that many attacks of migraine can be directly traced to 
indulgence in some article of food which the patient knows at the time 
is almost certain to produce a seizure. When such is the case, an 
emetic will often prevent the development of more than the premoni- 
tory symptom of a paroxysm. 



CHAPTER III. 

PATHOLOGY OF THE THORACIC SYMPATHETIC. 

The great thoracic sympathetic nerve controls the vaso-motor in- 
nervation of the superior extremities, the trunk, the mtra-thoracic 
organs, and the spinal cord. Physiological experimentation upon the. 
ganglia and nerve of that portion of the great sympathetic leads to 
the production of phenomena analogous to those which result from the 
excitation and paralysis of the cervical sympathetic. Still, up to the 
present time, we have at our disposal only a small number of instances 



864 DISEASES OF THE SYMPATHETIC NERVOUS SYSTEM. 

of vaso-motor troubles consecutive to lesions of the thoracic sympa- 
thetic, or of the organs to which it is distributed. 

We have seen, from the cases previously given, that the compression 
exercised by aneurisms of the arch of the aorta and of the thoracic 
portion of this vessel on the left sympathetic reacts ordinarily on the 
cervical sympathetic of the same side, and that it gives rise to oculo- 
pupillary and, more rarely, to vaso-motor disturbances of the corre- 
sponding side of the face. In addition, the phenomena in question were 
accompanied in a certain number of cases by an acceleration of pulse, 
attributed by authors to the compression of the cardiac filets of the 
great sympathetic, which is regarded as an accelerator nerve of the 
heart. 

Besides these vaso-motor troubles of the face consecutive to com- 
pression of the thoracic sympathetic by an aneurism of the aorta, we 
must note the redness of the cheeks, with elevation of local tempera- 
ture, observed in cases of pneumonia. M. Gubler, who has specially 
studied this phenomenon, has called attention to the fact that, in uni- 
lateral pneumonia, the redness is almost always limited to the cheek of 
the corresponding side. On the other hand, it is established from the 
researches of M. Lepine that, in pulmonary affections, such as pneumo- 
nia and tuberculosis confined to one lung, there exists a very notable 
difference of temperature in the two sides of the body — a difference 
which is almost always in favor of the side corresponding to that of 
the diseased lung. This difference may amount to one or two degrees 
Centigrade at the extremities of the limbs, while in the axilla? it is only 
a few tenths of a degree. 

Quite recently Seeligmuller, in a memoir which we have had several 
occasions to cite, has called the attention of physicians to the adhesions 
which, in the case of lesions of the summit, the lung, and its pleural 
covering, contract with the thoracic sympathetic. This morbid condi- 
tion occasions an irritation of the nerve, to which a state of paralysis 
succeeds. In the same way we account for the congestive spots on the 
cheeks and the dilatation of the pupils observed in tuberculous indi- 
viduals. In a certain number of cases of unilateral tuberculous lesions, 
these oculo-pupillary and vaso-motor disturbances are limited to the 
side corresponding to that of the diseased lung. Thus, in the instance 
of a woman twenty-four years old affected with catarrh of the apex of 
the left lung, there was mydriasis of the same side. In a man thirty- 
eight years of age, who had pleuro-pneumonia of the left side dur- 
ing ten years back, and a large cavity in the apex of the same lung, 
it was observed, six months before the fatal termination, that at times 
the cheeks and the ears, markedly on the right side, were subject to 
intense congestion, while, simultaneously, the pupil of the same side 
was contracted. In the case of a woman sixty-seven years old, affected 
with pleuro-pneumonia of the lower lobe of the right lung, there was 



PATHOLOGY OF THE ABDOMINAL SYMPATHETIC. 865 

developed a bed-sore, limited to the buttock of the same side, and which 
took four months to heal. Six months after the cure of the pleuro- 
pneumonia, the phenomena of paralysis of the sympathetic — a marked 
contraction of the pupil and of the palpebral opening of the same side — 
were observed. Indeed, the left side of the face and corresponding 
ear were often the subjects of congestion, which made a marked con- 
trast with the paleness of the right side of the face. Again, in a man 
thirty-one years of age, who, within the period of a year, had suffered 
from five attacks of pleuro-pneumonia of the right side, the pupil of 
the corresponding side was contracted. The patient had himself ob- 
served that on this same side there was a profuse perspiration when- 
ever he exercised physically, and, above all, when he drank. 

Dr. Fleischman, 1 of Vienna, has called attention to like facts, in a 
work on chronic pneumonia of the apex of the lung in infants. He has 
shown that in such cases there are vascular troubles limited to one side 
of the face or head, and transient unilateral erythema, with elevation 
of the local temperature. 



CHAPTER IV. 

PATHOLOGY OF THE ABDOITIXAL SYMPATHETIC. 

The great sympathetic contributes to form, with the vagus, the 
several plexuses which preside over the function of innervation of the 
organs contained in the abdominal cavity. The disorders which have 
their seat in these plexuses are manifested by painful sensations, by 
motor troubles, by exaggerated or insufficient movements of the con- 
tractile tissues which enter into the constitution of the abdominal 
organs, and by circulatory and secretory troubles. 

In the affection known as cramp of the stomach (gastralgia), there 
is a veritable contraction of the walls of this organ, which produces 
compression of the terminal extremities of the nerves of the stomachal 
plexus and violent pain. The pain is, hence, only a consequence of 
the motor trouble. However, for M. See the gastric pain is generally 
due, not to a contraction, but to a distention of the stomach by gas, 
and the consequent stretching of the nerves resulting therefrom. 

The centres w^hich regulate the secretory function of the stomach 
appear to be situated in the walls of this organ. In fact, the division 
of the pneumogastric nerves, as well as the destruction of the plexus 
of Auerbach and of Meissner with ammonia (Schiff), has no influence 
over digestion, and consequently over the secretion of gastric juice, 
Larnaensky has established this fact in animals, from which he had 

1 Wiener Prcsse, No. 20, 1876. 
56 



866 DISEASES OF THE SYMPATHETIC NERVOUS SYSTEM. 

extirpated the coeliac plexus. We must, therefore, admit an autonomy 
of the gastric vaso-motors, similar to that of the autochthonous ganglia 
of the heart and intestines. It is evidently by the intermediation of 
these inter-parietal plexuses that troubles of digestion of a reflex char- 
acter are produced — for example, the sudden arrest of digestion through 
the influence of a violent emotion. We have in colic another func- 
tional trouble of the abdominal plexuses, one which is, in reality, a neu- 
ralgia of the coeliac plexus. Lead-colic is, in some respects, the type 
of this variety of neuralgia. Recently Harnack has published the re- 
sults of his experimental researches on the physiological action of lead, 
from which it appears, in addition to other facts, that the metal excites 
the autonomous ganglia situated in the walls of the intestines. In man, 
this excitation is especially manifested by a generalized contraction of 
the intestinal canal, which explains the obstinate constipation and 
colics which are such constant symptoms of chronic saturnine intoxica- 
tion. In animals, however, this intoxication occasions, on the contrary, 
profuse diarrhoea, for the reason that lead, by exciting the autonomous 
ganglia of the intestines, produces an exaggeration of the peristaltic 
movements of these organs. 

It is also to an excitation of the nervous plexuses which ramify in 
the walls of the excretory canals of the liver that are to be attributed 
the painful paroxysms known as hepatic colic. Here the agent of ex- 
citation is a biliary calculus, plugging up the choledic or cystic duct, 
and which, by reflex action, causes the contraction of the w T alls of this 
canal. A strong compression of the nervous plexuses which send 
numerous branches to the walls of the excretory ducts of the bile is 
thus produced. Accessions of nephritic colic are developed by an 
identical mechanism. And there is also a vesical neuralgia, character- 
ized, at the same time, by pains and strangury, this last being the 
result of reflex spasm of the bladder, which is due to the pain seated 
in the walls of this organ. 

The experiments instituted by Rochefontaine demonstrate that, if, 
in an animal, we tie at the same time the splenic artery and the nerves 
of the splenic plexus, the spleen becomes congested, while, on the 
contrary, it would seem as if the vessels should empty themselves of 
their contents. To explain this apparently paradoxical congestion, it 
is said that there is produced a true aspiration of blood to the splenic 
veins, by reason of the paralytic relaxation of the non-striated fibres 
of the spleen, caused by the ligation of the nerves distributed to that 
organ. However correct this interpretation may be, the experiment 
of Rochefontaine may, in a certain way, explain the development of 
splenic congestion in adynamic fevers, which are characterized in gen- 
eral by a marked atony of the nervous system, and in particular of 
the splanchnic nerves. 

The greater number of the congestive phenomena, which have the 



PATHOLOGY OF THE ABDOMINAL SYMPATHETIC. 867 

uterus as their situation, take their point of departure in an irritation 
of the nervous ramifications which the genital plexus sends to the 
womb and its anexa?. It is the fact, also, as regards the more or less 
painful contractions of which this organ is the seat, either in the 
pregnant or non-pregnant condition. 

Finally, the abdominal sympathetic, which, in the physiological 
state, gives an absolutely unconscious sensibility to the viscera, be- 
comes the seat of extremely violent pains when it is deranged in its 
functions. These pains are especially apt to occur when the terminal 
ramifications of the visceral plexuses are compressed, either by the 
contraction or distention of the walls of a hollow organ, or by a wound 
or injury. Every one can recall in his own experience the intense 
pain caused by a blow on the epigastrium or on the testicles. These 
visceral plexuses are, besides, the point of departure for reflex phenom- 
ena, originating either at the places injured or at a distance. A painful 
sensation starting from the testicle leads, at first, to a contraction of 
the muscular tissue of the scrotum, with retraction of the testicles. 
When this pain reaches a sufficient degree of intensity, the walls of the 
abdomen, and of the several hollow viscera contained in the abdominal 
cavity, enter also into contraction. There may even, in certain cases, 
be developed general convulsions, with or without lipothymia, the re- 
sult, doubtless, of the reflex contraction of the vessels of the nervous 
centres, and of the olighemia resulting therefrom. The painful irrita- 
tions transmitted to the terminal ramifications of the splanchnic nerves 
cause also contractions of the abdominal vessels. Soon, however, 
these relax, and then there is a stagnation of blood in the abdominal 
vessels, through, the formation of a true depot capable of holding the 
whole of the blood in motion, when their paralytic relaxation passes 
certain limits. Thus are explained the paleness of the face, and of the 
skin generally, the cyanosis, the coldness of the extremities, the phe- 
nomena of cerebro-spinal anaemia, and the smallness and rapidity of the 
pulse, that are observed in all cases of peritoneal irritation, and also in 
the coma and stupor which ensue on severe wounds and injuries — a 
state designated, by English and American surgeons, shock. Goetz has 
realized the conditions under the influence of which this state is 
developed, in his well-known experiment, which consists in striking 
the belly of a frog against the edge of a table. He has seen the enor- 
mous development of the abdominal vessels and the ischaemia of other 
regions which at once ensue, and which entirely explain the morbid 
phenomena observed in the similar instances to which we have called 
attention. 



SECTION VI. 

CERTAIN OBSCUEE DISEASES OF THE 
NERVOUS SYSTEM. 



CHAPTER I. 

ACUTE ASCENDING PARALYSIS {LANDRY'S PARALYSIS). 

In the year 1859 Landry described a form of paralysis which be- 
gan in the lower extremities and rapidly extended upward, involved 
successively the muscles of the upper extremities, of the trunk, and 
finally of resjDiration. The course of the disease lasted but a few days 
and terminated in death. No lesion, which could in» any manner be 
related to the symptoms, was discovered. Since then other cases simi- 
lar in character to Landry's have been reported from time to time. 
In some of these, palpable lesions were observed, in others nothing 
was discovered. 

Westphal, 1 in his exhaustive article on this subject, showed that 
those cases in which anatomical lesions were found were cases of mye- 
litis and of meningeal haemorrhage, and that the resulting symptoms 
were not identical with those of Landry's paralysis. 

Symptoms. — Premonitory symptoms may or may not be observed. 
Sometimes there is slight fever, or there may be a feeling of weak- 
ness and lassitude, pains in various parts of the body, and numbness 
and tingling in the hands and feet. Again the first symptom to 
attract the patient's attention will be a decided weakness, usually first 
manifested in the feet and legs, but sometimes beginning in the hands. 
This weakness rapidly increases to profound paralysis. The upper 
extremities are affected simultaneously with the lower extremities, or 
else very soon afterward. The muscles of the trunk are next in- 
volved. This is followed by shortened and labored respiration, and 
by inability to defecate on account of the paralysis of the abdominal 
muscles. As the paralysis ascends there will be increased difficulty in 

1 Archiv fur Psychiatrie, 1816, No. 6. 



ACUTE ASCENDING PARALYSIS. 869 

"breathing, which is often paroxysmal ; indistinct speech and inability 
to swallow, and sometimes by double facial paralysis. If sensory 
symptoms are present at all, and they usually are not, there will 
simply be a slight hyperesthesia of the skin or a slight anaesthesia. 

The muscles, soon after paralysis supervenes, become flabby and 
flaccid, but they continue to respond to both forms of electrical exci- 
tation. The electrical reactions of degeneration are not exhibited. 
The reflexes, both superficial and deep, are usually lost. 

Causes. — Little is known relative to the etiology of this remark- 
able disease. Men seem more liable than women to suffer from it. 
Cold, syphilis, typhoid fever, and other exhausting diseases have 
been named as prominent causes. Westphal l considers that some toxic 
agent acting on the nerve centres through the blood is responsible for 
the peculiar symptoms exhibited. I am strongly inclined to accept 
this view of the case, but as yet the question has not been satisfacto- 
rily determined. 

Diagnosis. — Acute ascending paralysis may be confounded with 
multiple neuritis, with acute anterior poliomyelitis, and with acute 
central myelitis. In multiple neuritis there is severe pain and tender- 
ness over the course of the inflamed nerves. The muscles atrophy, 
and electrical degenerative reactions are present. Anterior poliomye- 
litis may likewise be differentiated from Landry's paralysis by the 
rapid muscular atrophy and by the presence of the electrical reactions 
of degeneration. 

In acute central myelitis, though there may be paralysis of motion, 
there will also be severe sensory symptoms and paralysis of the bladder 
and of the rectum, symptoms which are not observed in acute ascending 
paralysis. There are no other affections which resemble this disease. 

Prognosis. — Acute ascending paralysis is usually fatal. Although 
instances have been reported in which recovery has taken place, there 
is reason to believe that all of them were not cases of the disease 
under consideration. Where the course of the disease is rapid and 
when the cranial nerves become involved, the prognosis is hopeless. 
In cases in which the disease develops slowly and does not advance 
so as to implicate the nerve centres in the medulla, the prognosis is 
not so grave. All 'cases must be regarded as serious as long as the 
paralysis is ascending. 

Morbid Anatomy and Pathology. — In typical cases of acute ascend- 
ing paralysis no anatomical lesion is discovered. In some instances 
changes have been noted in the spinal cord, in the meninges, and in the 
medulla, but these cases, as TTestphal points out, are not clearly 
shown to have been instances of the disease under consideration. It i: 
probable, as has already been stated, that some toxic agent in the 
blood, acting on the nerve centres in the spinal cord and medulla, is 

1 Op. cit. 



870 CERTAIN OBSCURE DISEASES OF THE NERVOUS SYSTEM. 

responsible for this condition. This theory is in part substantiated by 
the frequent concurrence of inflammation of the spleen and lymphatic 
glands with Landry's paralysis, these symptoms often depending upon 
a toxic condition of the blood. Nothing definite, however, has as yet 
been ascertained, the question still being mainly speculative. 

Treatment. — There is very little to be said on this subject. The 
internal administration of ergot, iodide of potassium, and mercury 
have seemingly been followed by beneficial results in some cases ; in 
others they have not been efficacious. Counter-irritation to the spine, 
such as blisters, cold, heat, and electricity, have been recommended, 
but it can not be claimed that much benefit has been derived from 
their use. Tonics, fresh air, passive exercise, and moderate active 
exercise, if it be possible, should exert a beneficial influence. 



CHAPTER II. 

MYXCEDEHA. 

It is very doubtful whether myxcedema can properly be regarded 
as a disease of the nervous system, yet there are so many nervous and 
mental symptoms associated with it that a brief reference to it will 
not seem out of place. 

The first account of the remarkable disease now known, according 
to the suggestion of Dr. Ord, 1 as myxcedema, was given by Sir Will- 
iam Gull. 2 He did not, however, attempt any very complete descrip- 
tion of the cases that had come under his observation, nor enter at an^ 
length into a consideration of the morbid anatomy and pathology of 
the disease. His main object appeared to be to draw attention to a 
well-marked and probably not uncommon affection, which up to that 
time had not been differentiated. 

Subsequently Dr. Ord, in the paper cited, made a very thorough 
exposition of the symptoms and morbid anatomy of the disease, which 
apparently leaves little to be discovered, except so far as the minute 
anatomy of the nervous structures is concerned. So positive are the 
data furnished by the writer, that it seems to me proper to consider 
the affection under the head of " Diseases of the Brain." 

Before the Clinical Society, October 10, 18T9, Dr. Dyer Duck- 
worth 3 reported cases of the disease, and Dr. Ord read another paper 

1 " On Myxoedema, a Term proposed to be applied to an Essential Condition in the 
Cretinoid Affection observed in Middle-aged "Women." — Medico- Chirurgical Ti-ansactions, 
vol. lxi., p. 57. 

2 " On a Cretinoid State supervening in Adult Life in Women." — Transactions of the 
Clinical Society of London, vol. vii., 1874, p. 180. 

3 Lancet, vol. ii., 18*79, p. 577. 



MYXEDEMA.. 871 

on the subject. At the same time, Dr. Sanders, of Edinburgh, in the 
debate which ensued, mentioned the fact that several cases which he 
now recognized to be instances of myxoedema, had come under his 
observation. 

Subsequently Dr. George H. Savage 1 reported cases of this curious 
disorder, and gave photographs of two of Dr. Ord's cases. 

In this country, the only case reported is one which occurred in my 
own experience, and which, with an account of what had been previ- 
ously written on the disorder, formed the basis of a memoir which I 
read before the American Neurological Association, June 16, 1880. 2 

Since that time two cases have been reported by Dr. Thomas 
Inglis. 3 

This, I believe, embraces all the literature of the subject up to the 
present time. 

Symptoms. — Myxoedema is a disease which, as Dr. Ord has shown, 
has for its patho-anatomical feature the deposit of a mucoid substance 
in various parts of the body, especially in the skin ; or a degeneration 
and proliferation of the connective tissue. Probably both these con- 
ditions coexist in some tissues. 

As a consequence of this state, an appearance resembling that of 
anasarca is produced, with the exception that the pressure of the finger 
on the part does not leave an indentation. The tissue is resilient, 
and not boggy like that into which water is infiltrated, as in ordinary 
oedema. 

The face has very much the appearance, so far as the swelling is 
concerned, of that which is met with in cases of the toxic effect of 
arsenic. There is a puffiness of the eyelids, the lips are prominent, the 
nostrils are swollen, and the cheeks over the malar bones are red from 
capillary congestion. 

Sir William Gull w T as much impressed with the "spade-like" ap- 
pearance, as he called it, of the hands and fingers. These latter are 
" clubbed," as they so frequently are in those cases of heart disease in 
which there is an impediment to the return of blood to the right side 
of the heart. 

The temperature of the body is, in all cases, below the normal 
standard. 

Thus far all the instances of the affection reported have been in 
adult women, unless an exception exists as regards one in a man oc- 
curring in Dr. Savage's experience, in relation to which there is some 
doubt as to its identity with myxoedema. 

The cerebral and nervous symptoms appear to be very decided. 

1 Journal of Mental Science, January, 1880, p. 417. 

2 " On Myxoedema, with Special Reference to its Cerebral Symptoms." — St. Louis 
Clinical Record, July, 1880, p. 97. Also, Neurological Contributions, No. III., 1881. 

3 Lancet, September 25, 1880, p. 496. 



872 CERTAIN OBSCURE DISEASES OF THE NERVOUS SYSTEM. 

The intellect is notably weakened, and replies to questions are given 
in a sluggish and inexact way. The memory is imperfect, and the pa- 
tient experiences a lack of confidence in herself both as regards men- 
tal and physical power. The special senses are more or less perverted, 
and there are sometimes hallucinations or delusions. One case cited 
by Dr. Savage " was distinctly maniacal, sleepless, incoherent, violent 
at night." The most ordinary mental condition met with is, however, 
a lassitude or stupidity resembling the state generally known as acute 
dementia. 

Such are the most marked features of the disease as described by 
the authorities I have mentioned. 

Since the appearance of Sir William Gull's and Dr. Ord's papers, 
my attention has been directed to the subject, and I have been on the 
look-out for cases similar to those described by these gentlemen. Two 
instances only of the affection, but these of a most undoubted charac- 
ter, have as yet come under my observation: 

Mrs. H. S., aged forty-one, consulted me first, April 22, 1880. I 
saw her again April 29th, and again May 6th. Her appearance was 
that of a person suffering from general oedema, the consequence of 
heart or kidney disease. The lower eyelids and the face immediately 
below them were turgid ; the skin over the forehead was rough and 
swollen in spots ; the nose was thick ; the lips, especially the lower one, 
protruded like those of a person who has received a severe blow upon 
the mouth ; and the skin over the malar bones was not only thickened, 
but for a space on each side the size of a dollar was red with a hectoid 
fiush. 

The neck was also greatly swollen, as were likewise the hands. All 
the fingers were "clubbed," but there was no incurvation of the 
nails. 

Extending my inspections, I found that t the whole surface of the 
body was similarly affected. At no place, however, could pitting be 
produced by pressure. As soon as the end of the finger was removed, 
the depressed surface returned to its ordinary level. 

It was very evident that this was a case of myxoedema, and 
the continuance of my inquiries served to confirm the impression 
derived from a simple inspection of the more obvious characteristics 
of the case. 

The general sensibility of the skin was markedly diminished. 
Thus, on the cheek, the tw T o points of the sesthesiometer could barely 
be distinguished when separated to the extent of an inch and a half — 
three times more than the normal distance ; and at the ends of the 
fingers, where they should have both been felt at a distance apart of 
the twelfth of an inch, they had to be separated five twelfths of an 
inch before each was perceived. A like condition existed in the skin 
of the trunk and lower extremities. 



MYXEDEMA. 873 

At an early period she had suffered from pains in various regions 
of the head, but latterly these had disappeared, and there had been no 
similar disturbances of sensibility in other parts of the body. On the 
contrary, as the resthesiometer indicated, sensibility was diminished. 
The ends of the fingers felt as if there were "tight thimbles on them," 
to use her own expression, and the soles of her feet as though they 
were padded or cushioned. The various sensations of numbness were 
present more or less in the face, the end of the tongue, and the arms 
and legs. 

The muscular power of the patient appeared to be decidedly weaker 
than was normal. The gait was staggering, the feet were not lifted 
clear of the ground, the grasp of the hands was feeble, and the articula- 
tion was sluggish and indistinct. There was marked difficulty of co- 
ordination both in the upper and lower extremities. Although the 
patient could stand with the eyes shut, she walked with an uncertain 
step unless her eyes were directed to the ground, as is the case in loco- 
motor ataxia. She could not put the finger on any given part of the 
face unless she had her vision to guide her, and even with that assist- 
ance she did not readily and with certainty direct the movements of 
the hands. 

The other special senses besides the touch, which, as I have said, 
was markedly lessened in acuteness, were all more or less deranged. 
Ophthalmoscopic examination showed the existence of neuro-retinitis 
in both eyes ; objects looked blurred, and were generally apparently 
surrounded with a halo. Occasionally she had had momentary double 
vision. The pupils were equal in size, but extremely slow to respond 
to an increased or diminished amount of light. 

The hearing was diminished in acuteness. With the left ear she 
could not hear the ticking of a watch at a greater distance than twenty 
inches, and with the right ear, twenty-six inches. The tuning-fork 
placed on the forehead was heard, but the sound was not intensified 
when the meatus was closed. On the contrary, it seemed to be less- 
ened. I was, therefore, of the opinion that the auditory nerves were 
affected. The Eustachian tubes were pervious. 

At one time there had been tinnitus, but latterly this had disap- 
peared. There was no impaction of cerumen, and the drum-heads 
were apparently healthy. 

The senses of taste and smell were markedly diminished in power, 
the latter being almost entirely abolished. The lining membrane of 
the mouth and fauces had lost a great deal of its normal sensibility. 
Thus, she could not, by the taste or the feeling, from the contact with 
the tongue and mucous membrane, distinguish a clam from an oyster, 
or fish from roast beef. 

The mental phenomena were not less strikingly exhibited. There 
were frequent hallucinations, both of sight and hearing, and delusions 



874 CERTAIN OBSCURE DISEASES OF THE NERVOUS SYSTEM. 

that attempts were being made by certain Frenchmen she spoke of to 
injure her with oil of vitriol, which, she declared, they put into the bed 
in which she slept and the food she ate. 

There was manifest deterioration of the mental power. In answer- 
ing the simplest question she looked fixedly at the interrogator for fully 
a minute before speaking, apparently not comprehending its purport, 
or else uncertain what reply to make. Some quite simple matters she 
evidently did not understand at all. Thus she could not tell me how 
much sixty and twenty-five made ; and when I asked her what a book 
was made of, she fixed her eyes on me for some time and finally said, 
" Oh, all those things," and I could get no other answer out of her. 

Her memory was equally weakened. She required much prompt- 
ing before she could tell where she lived, and made several errors, 
which, however, she corrected, herself, in giving me the names of her 
children. 

Perhaps her memory for words was slightly impaired, but certainly 
there was no decided aphasia. She could, without much difficulty, give 
the names of all articles I mentioned to her, and she exhibited no other 
evidence of defective articulation than that due to paresis of the tongue. 

She slept badly, often awoke startled, and was pacified with diffir 
culty. 

The hallucinations to which I have referred were not fixed. Those 
of hearing consisted of human voices telling her how the ''French- 
men " were going to proceed against her, and of the " Frenchmen " 
themselves abusing and threatening her. Those of sight were of en- 
tirely different objects, for, strange to say, she never saw the " French- 
men." They consisted generally of apparitions of friends who had 
long been dead, and were most frequent in the afternoon and evening. 

When I add that her appetite was bad, that her bowels were con- 
stipated, that the urine contained a large excess of urates, without other 
abnormality, that the pulse was slow and feeble, and that the animal 
temperature was, in the axilla and under the tongue, never above 96° 
Fahr., and often half a degree below this, I have given as full an 
account of the symptoms as is necessary for a full understanding of 
the case. 

I saw nothing more of this patient till December 11, 1880, when 
I again subjected her to careful examination. I then ascertained that 
the temperature in the axilla and under the tongue had fallen to 94*8°, 
and that the electric contractility of the muscles to both the galvanic 
and faradaic currents was markedly lessened in all parts of the body. 
Generally, the disease had advanced. The strength was reduced, the 
turgidity of the face and limbs had increased, and the sensibility of 
the skin was more impaired than when I last saw her. In addition, the 
vision and hearing had become so much affected that she was almost 
blind and deaf. 



MYXCEDEMA. 



875 



As regards the mental symptoms, there had been no advance, and 
in some respects a slight degree of improvement had taken place. 
Thus, while her mind appeared to be fully as sluggish as when I first 
saw her, the hallucinations and delusions which were then present had 
disappeared, and no others had taken their place. In fact, she had for- 
gotten all about the " Frenchmen " who were formerly such causes of 
discomfort to her. 

Her fingers (Fig. 116) were more enlarged at the extremities than 
they were when she was last under my charge, and I discovered that 

Fig. 116. 




her toes were in a like condition. The tongue, which at former exam- 
inations exhibited no evidence of departure from the normal appear- 
ance, was now decidedly swollen, and the speech was consequently 
more labored and indistinct. 

The urine was of 1018 specific gravity, and was free from albumen 
and sugar. 

But while writing this chapter (January 7th) a second case has come 
under my observation, differing in no essential respect, except as regards 
the stage of the disease, from the one the details of which have just 
been given. Of this instance I am enabled to present a portrait taken 
from a photograph (Fig. 117). The patient, a female, aged thirty- 
three, constitutes what I should consider a typical case of myxcedema. 
With her, as in the other example, the mental symptoms began before 
any swelling was observed in the face or other part of the body, and 
consisted of depression of spirits amounting almost to melancholia. 
There are as yet no delusions. 

The temperature under the tongue is 95*5°. There is a good 
deal of irregular action of the heart, and there is very persistent 
insomnia. 

The swelling is more noticeable about the face and neck than in 
other parts of the body. The fingers are, however, beginning to 



876 CERTAIN OBSCURE DISEASES OF THE NERVOUS SYSTEM. 

show the "spade-like" form, and the appearance of oedema is notice- 
able about the arms and chest. 

The further consideration of this case is deferred till I have had 
the opportunity of studying it with thoroughness. 



Fig. 117. 




Causes. — Sax appears to be a strong predisposing cause, for, of all 
the cases observed, only two have been observed in males. One of 
these— and it is somewhat doubtful if this was a true instance — oc- 
curred in the experience of Dr. Savage, the other in that of Dr. Inglis. 
Age is also a determining predisposing cause, for all the cases have 
been observed in persons who have reached middle life. 

Pregnancy has been thought to exercise a predisposing influence 
over the causation of myxoedema, but, as I think, without sufficient 
reason. As to the immediate or exciting causes, nothing is absolutely 
known. 

Diagnosis. — Myxoedema is not a disease of difficult recognition. 
The mental phenomena and the peculiar swelling of the body will of 
themselves serve to diagnosticate the disease from any other. This 
oedema, unlike that due to the accumulation of serum in the cellular 
tissue, does not pit upon pressure, but is, on the contrary, resilient, 
just as is a rubber ball filled with air. The clinical history will serve 
to distinguish the swelling of the face from the like condition in- 
duced by large and continued doses of arsenic, and the clubbed fingers 
from the similar formation attendant upon those cardiac affections 



MYXEDEMA. 877 

which interfere with the return of the blood to the right side of the 
heart. 

In scleroderma there is a similar swelling of parts of the body, due 
to hypertrophy of the skin, but in this affection the surface is hard, 
and there is a sensation of tightness about the parts involved which is 
not present in myxcedema. Moreover, there is no permanent reduc- 
tion of the temperature of the body in scleroderma, as is met with in 
myxcedema, and there are no mental symptoms, such as form so strong 
a feature of the latter disease. Scleroderma is a disease of a much 
younger period of life than is myxcedema, most of the cases observed 
having been under thirty-five years of age. 

Notwithstanding, however, these marked points of difference, it is 
quite probable that the two affections have been confounded. 

Prognosis. — The prognosis is bad. Several cases have terminated 
fatally, and in no one has there been any amelioration from medicinal 
treatment. Improvement has been observed in a few cases in which 
operative measures have been resorted to. 

Morbid Anatomy and Pathology. — In regard to the connection of 
the phenomena with the morbid anatomical condition to which refer- 
ence has been made, two views have been expressed. 

Dr. Ord regards the symptoms as being directly due to the fact 
that the peripheral terminations of the nerves are so surrounded and 
compressed by the mucoid tissue deposited about them that they are 
prevented receiving impressions in their full force, and that, hence, 
the central organs of the nervous system act less energetically than 
when excitations reach them in full force. 

The other view is that the symptoms result directly from the in- 
ability of the thyreoid gland to perform its functions. The evidence 
so far adduced is decidedly favorable to the latter theory. In several 
instances in which the thyreoid gland has been removed myxcedema 
has supervened. This does not invariably happen, as Billroth has 
shown, yet it is undeniable that in a certain proportion of cases myx- 
cedema follows total extirpation of the thyreoid gland, while it is 
equally certain that the symptoms of that disease do not appear if one- 
third of the gland is left in situ. The fact that when myxcedema- 
tous symptoms appear they can often be relieved by transplanting 
healthy thyreoid glands into the abdominal cavity of the affected in- 
dividual has been proved by actual experiment. Schiff has shown 
that myxcedema can be everted after thyreoidectomy if other thyreoid 
glands are attached to the internal abdominal walls or to the mesen- 
tery ; and von Eiselberg's 1 experiments on cats confirm Schiff 's results. 
Bicher 2 relates the case of a woman from whom the entire thyreoid 
gland was unintentionally removed. She soon developed symptoms 

1 "tleber Tetanie in Anschlusse an Kropf-operationen," Wien, 1890, 

2 "Sammlung klinisebe Vortrage," 357, 1890. 



878 CERTAIN OBSCURE DISEASES OF THE NERVOUS SYSTEM. 

of myxcedema. A piece of thyreoid gland was then transplanted into 
the abdominal cavity. Marked improvement in the patient's condition 
ensued and lasted for some time, but eventually the symptoms of 
myxcedema reappeared, necessitating a repetition of the operation, 
which was again followed by improvement. Other cases are not 
wanting which show the close connection between total extirpation of 
the thyreoid gland and myxcedema, but it is perhaps premature in the 
present state of our knowledge to accept this evidence as conclusive. 

Treatment.— Nothing in the way of internal medication appears to 
have been of any material service in the treatment of myxcedema. 
Electricity, tonics, and the most favorable hygienic surroundings ap- 
parently make no impression on the disease. Following the investi- 
gations of Schiff, Bircher 1 attempted transplanting thyreoid glands 
into the abdominal cavity with partial success. Koehn, according to 
Horsley, 2 performed a similar operation in 1883, but the graft was 
absorbed, and the patient was, therefore, not benefited. Hearing of 
Bircher's case, he repeated the operation on five different cases. In 
two of the cases the transplanted thyreoid gland was stitched to the 
abdominal walls ; in three other cases it was simply placed within the 
abdominal cavity. One of the patients was greatly improved. Other 
attempts show that, though the operation is not always followed by 
improvement of the patient's condition, yet it affords the only hope of 
relief from an otherwise incurable malady. 



CHAPTER III. 

ACROMEGALY. 

Although isolated instances of enormous hypertrophy of the ex- 
tremities had been observed for a number of years, it had not been 
considered as a distinct type of neurosis until Marie's description of 
the disease was published. Since then careful investigation has thrown 
a good deal of light upon the nature of this obscure affection. 

Symptoms. — Very little has been added to the symptomatology of 
the disease since Marie's very complete description. The first evi- 
dences of hypertrophy usually begin in early life, and are gradual in 
their development. The hands, feet, and head slowly enlarge till they 
are considerably out of proportion to the rest of the body. In the 
upper extremities the hypertrophy begins in the fingers, and gradually 
advances till the entire hand becomes enormous. The form of the 
hand is rarely out of proportion. The lines in the fingers and hands 
are deeply marked, and are bordered by massive ridges of hypertro- 

1 Op. cit. 2 British Medical Journal, London, 1890, ii., 786. 



ACROMEGALY. 879 

phied skin. The nails are flat, wide, and short. The wrist is gener- 
ally slightly increased in volume, but much less so than the hand, 
while the forearm and arm are usually unaltered. The feet present 
the same general characteristics ; they become huge in size, flat, and, 
like the hands, are surmounted by ridges of hypertrophied skin. The 
face becomes elongated, principally from the enlargement of the in- 
ferior maxillary bone. The other bones of the face enlarge, thus dis- 
figuring the face to a considerable degree. This facial deformity is 
enhanced by a wonderful development of the nose, which increases in 
all dimensions, and frequently attains an enormous size. The super- 
ciliary ridges become more prominent, and the lips, ears, and eyelids 
are thickened and massive. The cranium often participates in this 
gradual growth, and when it does so it usually develops equally in 
all dimensions. The muscles are usually flabb}', and are far from pow- 
erful, though they are not sufficiently weakened to be termed paretic. 

Thomson, 1 in his able paper on this subject, shows that headache 
is a common symptom ; the sight may be impaired, and at times lost 
altogether ; the speech is sometimes interfered with ; there is often 
excessive thirst and hunger ; and the disease is frequently complicated 
by diabetes mellitus. In women, amenorrhoea is often observed. 

Prognosis. — There is little to be said on this subject in any way 
favorable to the affected individual. No instance of a cure has. as 
yet been reported. The patient may live for a number of years, but 
gradually weakens, and either dies of exhaustion or of some intercur- 
rent affection. 

Morbid Anatomy and Pathology. — The disease is evidently a tropho- 
neurosis of obscure origin. The enormous increase in size of the ex- 
tremities can only be accounted for by the theory of an abnormal and 
excessive stimulation of the trophic centres supplying the hypertro- 
phied parts. It has been urged that atrophy of the thyreoid gland, 
which has been sometimes observed to occur in connection with 
acromegaly, might be the pathological foundation for the disease, but, 
although it seems probable that the thyreoid gland is directly con- 
cerned in the proper nutrition of tne human body, it has not been 
demonstrated that atrophy, or other disease of the thyreoid gland, is 
at all a constant feature of acromegaly. According to Thomson, 2 in 
every case, except the one reported by Virchow, 3 the pituitary body 
has been found to be greatly enlarged by a hyperplasia of its normal 
elements, and the same change affects the ganglia and larger nerve- 
trunks of t the sympathetic nervous system. But in Yirchow's case 
this enlargement of the pituitary body did not exist. One negative 
case, such as this one, is sufficient to upset a theory, no matter how 

1 Journal of Anatomy and Physiology, London, 1889-'90, xxiv., p. 475. 

2 Op. cit. 

3 Berliner Jclin. Wocliensclirift, 1889, xxvi., p. 81. 



880 CERTAIN OBSCURE DISEASES OF THE NERVOUS SYSTEM. 

plausible it may appear at first sight. It is quite probable that the 
enlarged pituitary body may be the result of the same exaggerated 
hypertrophic process which takes place simultaneously in other parts 
of the body. No other lesions have been observed which throw any 
light upon the morbid anatomy of this strange affection. 

Treatment. — So far no treatment of any kind has been efficacious 
in arresting the progress of this disease. A general tonic treatment, 
conjoined with proper hygienic surroundings, may serve, for a time, 
to improve the patient's condition. 



CHAPTER IV. 

THOMSEN'S DISEASE {MYOTONIA CONGENITA). 

It is extremely doubtful whether Thomsen's disease can be consid- 
ered in any respect as an affection of the nervous system. It is proba- 
bly primarily a muscular disorder, yet there is sufficient doubt in my 
mind to warrant the insertion of this chapter in its present position 
until the precise nature of the pathological conditions which produce 
this disease are definitely ascertained. 

Symptoms. — Though Thomsen 1 was the first to give an accurate 
description of this peculiar malady, as he observed it in his own case, 
and in his son's, it was not until Erb 2 published the results of his 
study of over twenty cases of this disease that much light was shed 
upon its true nature. Thomsen's disease, or myotonia congenita, de- 
pends upon the inability of the affected individual to relax or to con- 
tract his muscles with facility after a period of rest. This stiffness 
and rigidity of the muscles may be slight at times, while at others 
there may be complete inhibition of movements. Continuous effort to 
move the muscles is gradually followed by dissolution of the tension, 
until finally the muscles can be moved freely and rapidly in all direc- 
tions. After a short period of rest the same condition of stiffness and 
immobility is found to exist again. An individual suffering from 
Thomsen's disease w T ho attempts to arise from his chair finds he is 
totally unable to do so. On the first attempt to stand erect, the mus- 
cles of the thighs become rigid ; gradually, if the efforts to arise are 
continued, the muscles relax, and the act is accomplished. The same 
condition is found to exist in the upper extremities. Any movement, 
from a state of repose, is executed with slowness and with difficulty, 
and sometimes cannot be performed at all until after several moments 

1 Archiv fur Psych, und Nervenheilkunde, 1876. 

2 " Die Thomsensehe Krankheit, 



THOMSEX'S DISEASE. 881 

of continuous effort. After the muscles have once been induced to 
act, they do so freely, under the stimulation of the will, until allowed 
to rest, when they are again found tense and stiff on the next attempt 
to perform a voluntary act. 

The muscles concerned in mastication, and also the muscles of the 
tongue and throat, are frequently affected, so that chewing the food 
and swallowing it are attended with great difficultv. The ocular mus- 
cles are seldom involved. 

There are no sensory symptoms of any importance, or which are 
characteristic of the disease. 

The electrical reactions, as described by Erb, 1 are very peculiar. 
Thus, he says : " If a large electrode is placed upon the nape of the 
neck, and a smaller electrode in the palm of the hand, there ensues, 
with the passage of a galvanic current from sixteen or eighteen cells, 
a steady tonic contraction of all the muscles of the arm. After one 
or two changes of the poles a series of wave-like contractions are seen. 
If the cathode is in the hand, these contractions begin at the wrist- 
joint and pass up the arm, gradually vanishing as they approach the 
shoulder. If the anode is in the hand, the waves pass downward. 
The contractions are rhythmical, and follow each other like waves pro- 
duced by throwing a stone into water. Sometimes there is an interval 
of a second of time between the sequence of waves." With moderate 
faradaic currents normal contractions of the muscles follow, but if 
strong currents are employed the muscles contract rigidly, and remain 
contracted for some time after the electrodes have been removed. 

Polar degenerative reactions, though they have been at times ob- 
served, are not at all constant, and are not pathognomonic of the dis- 
ease. Reflex excitability is very much exaggerated in the affected 
muscles, but the contractions which ensue when a muscle is struck are 
slow, and continue for a few seconds. 

Causes. — There is unquestionably a strong hereditary influence in 
the majority of cases that have been observed. Isolated instances, 
however, have been reported in which no hereditary taint could be 
discovered. The disease usually shows itself in early childhood, with- 
out depending upon any exciting cause, or at least upon any that can 
be detected. 

Diagnosis. — The peculiarities of Thomsen's disease render its con- 
fusion with any other affection very improbable. The peculiar elec- 
trical reactions which have never been observed in any other disease, 
and the rigidity of muscular actions, without the accompaniment of 
paralysis or atrophy, will be sufficient to readily determine the diag- 
nosis. 

Prognosis. — The disease begins in childhood and lasts as long as 
the individual lives, without sensibly diminishing the length of life. 

1 Op. at. 

57 



882 CERTAIN OBSCURE DISEASES OF THE XEKVOUS SYSTEM. 

No case has as yet been cured, and the probability of relief being 
afforded by treatment is very slight. 

Morbid Anatomy and Pathology. — Erb was the first to subject 
specimens of muscular tissue, taken from individuals suffering from 
Thomsen's disease, to a careful microscopical examination. He found 
the muscular fibres hypertrophied to three or four times their natural 
size, the nuclei of the muscular fibres were decidedly augmented, and 
the intermuscular connective tissue was slightly increased. Jacoby 1 
found changes similar to those discovered by Erb. The muscular 
fibres were hypertrophied to double their normal size, and were rounded 
instead of polygonal. The nuclei of the muscle-fibres were aug- 
mented, and both the internal and the external perimysium were in- 
creased in volume. These changes may be primarily myopathic, and 
they probably are, but it is not at all impossible that the hypertrophy 
of the muscular tissue may be secondary to morbid conditions in the 
central nervous system. The hypertrophy of the bones and softer 
tissue, as they occur in acromegaly, are probably the result of excessive 
stimulation of the trophic centres which are in direct connection with 
the hypertrophied parts. In Thomsen's disease, the enormous growth 
of the muscular fibres, and of their connective tissue, may depend 
upon a similar abnormal stimulation of trophic centres supplying the 
hypertrophied muscles. As I have previously stated, however, the 
probability of Thomsen's disease being primarily of myopathic origin 
is the stronger, but as yet neither theory has been conclusively proved. 

Treatment. — Nothing within the range of medical science seems to 
exert any beneficial influence upon Thomsen's disease. Thomsen 
found that severe muscular exercise was of service to him, and that 
when it was followed up systematically the muscular stiffness and 
rigidity was at its minimum. Other sufferers have made similar ob- 
servations, but no instance of a cure has resulted from this method of 
treatment. 



CHAPTER V. 

RAYNAUD'S DISEASE {SYMMETRICAL GANGRENE OF THE EXTREMITIES). 

Under the name of symmetrical gangrene of the extremities, M. 
Maurice Raynaud described for the first time in 1862 a variety of 
gangrene which since then has been given a place in systems of 
nosology as a distinct and morbid entity. It presents the curious 
feature of being developed independently of any lesion of the cir- 
culatory apparatus. 

1 Journal of Nervous and Mental Diseases, 1886. 



RAYNAUD'S DISEASE. 883 

• 
Symptoms. — Generally the affection is observed in young subjects, 

preferably in females, and with those who possess a neurotic diathesis. 

Cold, moral emotions, and troubles of menstruation, act sometimes as 

causes. 

As a rule, the gangrene attacks symmetrically the lower extremi- 
ties, more rarely the upper extremities ; sometimes, also, the nose and 
the ears. 

In the beginning the patient feels, in the parts which are about to 
be the seat of the gangrene, a sensation of tumefaction, which coin- 
cides with the paleness of the skin at the same points. At other times, 
the skin of the extremities is covered with bluish-colored spots. These 
are the indications of the interference with the circulation which pre- 
cedes the development of the gangrene. This local ansemia may, it is 
true, occur without there being any further advance. Then the parts 
primarily exsanguined become the seat of a temporary congestion, 
accompanied with more or less severe pains, before the circulation 
again becomes regular. The condition, in fact, resembles that induced 
by the local application of cold. This local ana3mia may disappear 
and reappear many times ; but, when it is the prelude to the mortifi- 
cation of the parts affected, the skin becomes covered with phlyctenae, 
dry, tense, like parchment, and assumes the black coloration peculiar 
to sphacelated tissues. The process of mortification is announced by 
extremely sharp pains, which the patients compare, ordinarily, to the 
sensations caused by burns. 

Morbid Anatomy and Pathology.— Inspection of the limbs affected 
with this kind of gangrene shows the absence of all lesions capable of 
producing obstruction of the vessels distributed to them. There is 
neither thrombosis, embolism, atheroma, nor any alteration whatever 
of the walls of the vessels. Moreover, M. Maurice Raynaud has 
called attention to the fact of the persistence of the pulse in the ex- 
tremities, the seat of the affection in question. 

This circumstance indicates clearly that, if the circulation is insuffi- 
cient for the proper nutrition of the tissues, it is not entirely abolished. 
To explain the development of the gangrene, it is sufficient to sup- 
pose the existence of a durable vascular spasm limited to the affected 
part ; and this is w T hat M. Maurice Raynaud has done. For him, the 
symmetrical gangrene of the extremities and the local ansemia which 
is its immediate cause are the consequences of a spasm of the small 
vessels, due to an excitation of the vaso-motor nerves which innervate 
their walls. This spasm may be of a reflex order, having for its point 
of departure a peripheral excitation having its seat within the extremi- 
ties threatened, or in some other organ — the uterus, for instance. 

This excitation will be reflected by the vaso-motor centre situated 
in the bulb. Naturally, the production of this vascular spasm and its 
persistence under the influence of an occasional cause of slight impor- 



884 CERTAIN OBSCURE DISEASES OF THE NERVOUS SYSTEM. 

tance suppose that the reflex centres of the cord are in a morbidly 
exaggerated state of excitability. 

M. Vulpian, while admitting the theory of a local vascular spasm 
as the cause of symmetrical gangrene of the extremities, believes that 
it is useless to allege the implication of the vaso-motor centres in the 
production of this spasm. This eminent physiologist contends that the 
reflex vascular constriction which presides over the development of 
symmetrical gangrene of the extremities is produced only by the inter- 
mediation of the ganglia situated in the course of the vaso-motor fibres 
at a short distance from their terminations in the vascular walls. The 
symmetrical disposition of the gangrene is more in accordance with 
this theory than with that which makes it depend upon a derangement 
of the central innervation. In fact, " if the local anaemia of the ex- 
tremities is so often symmetrical in the affection described by M. Ray- 
naud, it is explained by the fact that it affects subjects in whom the 
local predisposition is due to a general modification of the economy, 
and ought to be nearly equal in homologous parts of the two sides of 
the body." * 

M. Vulpian, moreover, contends that, if gangrene of vasoconstric- 
tive origin is always symmetrical, it will be necessary to get rid of some 
facts which, from a pathological point of view, naturally are embraced 
under M. Raynaud's designation. Thus, in this connection, he recalls 
the instance, adduced by M. Gubler, of a gangrene limited to one of 
the toes, occurring in a young woman in whom there was no evidence 
of a closure of the arteries of the corresponding limb. It would evi- 
dently be illogical to abstract from the so-called symmetrical gangrene 
a case of similar pathogeny, merely because the gangrene was uni- 
lateral. 

In a more recent work, M. Raynaud has published some cases of 
symmetrical gangrene of the extremities, in which the ophthalmoscope 
revealed the existence of a constriction in the central artery of the 
retina. Recently Stevenson 2 reported a case who had frequent attacks 
of partial and sometimes of complete loss of vision. The ophthalmo- 
scope showed that the central arteries of the retinae were constricted. 
This is, then, the basis for a new argument in support of the vaso- 
motor theory adopted by this author. As a practical consequence of 
the vaso-constriction theory, M. Raynaud recommends the use of de- 
scending galvanic currents applied to the vertebral column through- 
out its length These currents have the effect of weakening the ex- 
cito-motor power of the cord and bulb, and hence of combating the 
vascular spasm of central origin, which is the point of departure in 
symmetrical gangrene of the extremities. 

In connection with the affection 'described for the first time by M. 

1 "Lecons sur l'appareil vaso-moteur," tome ii., p. 620. 

2 Lancet, London, Nov. 1, 1890, p. 917. 



RAYNAUD'S DISEASE. 885 

Raynaud under the name of symmetrical gangrene of the extremities, 
mention must be made of the condition referred to by M. Vulpian 1 as 
symmetrical congestion of the extremities. 

The case observed was that of a patient in whom regularly every 
day there were accessions of pain and heat in all four extremities, espe- 
cially the legs. " The skin became red and very hot, the arteries of 
the feet, the pulsations of which could scarcely be felt in the intervals, 
during the paroxysms beat with great force, and appeared to be dilated. 
There was at the same time a very painful feeling of tension, and 
walking, by aggravating these troubles, became impossible. The pa- 
tient only found relief by plunging his feet and the lower part of his 
legs in cold water." M. Vulpian, with some reserve, is nevertheless 
disposed to see in this case an example of a symmetrical neurosis of 
the extremities, determining by reflex action the dilatation of the ves- 
sels of these parts 

Treatment. — Nothing in the way of treatment has yet been devised 
which in any way controls the manifestations of the disease except, 
perhaps, the continuous galvanic current. Raynaud 2 has described 
several cases which were relieved in this manner. The positive pole 
should be applied at the cervical region while the negative pole should 
be in contact with the hand. A moderate but continuous current 
should be allowed to flow daily, if possible, for fifteen or twenty min- 
utes at a time. 

1 Op. cit., tome ii., p. 623. 

2 Pub. of New Sydenham Soc, cxxi. 



SECTION VII. 

TOXIC DISEASES OF THE KEBVOUS 
SYSTEM. 



There are certain substances which, when taken into the body 
gradually and for a long time, manifest their poisonous influence more 
especially upon the nervous system. Among these, lead, alcohol, bro- 
mine, mercury, and arsenic, may be particularly mentioned. Several of 
these substances are used as slow poisons with criminal intent, others 
are habitually employed by many persons as stimulants, sedatives, or 
cosmetics, others are used in the arts, and hence enter the systems of 
those who are brought in contact with them, and some are prescribed in 
such doses in the treatment of disease as to produce upon the patient 
their characteristic physiological effects. 

It seems important that the peculiar phenomena which these sub- 
stances are capable of causing, with the rationale of their mode of ac- 
tion, and the treatment best adapted to obviate their deleterious effects, 
should receive some attention, and I shall therefore devote a few pages 
to their consideration. 



CHAPTER I. 

PLUMBISM. 



Symptoms.-— The phenomena manifested in the nervous system, as 
consequences of lead-poisoning, are lead-encephalopathy, paralysis, 
a spasmodic and painful affection called lead-colic, anaesthesia, and hy- 



a. Lead- Encephalopathy, — The symptoms referable to the brain, 
due to lead-poisoning, may be slight or severe. In the first case the 



PLUMBISM. 887 

patient suffers from headache, vertigo, and various other abnormal sen- 
sations, such as fullness, and constriction, and is at the same time in- 
capable of much intellectual exertion without suffering an increase of 
his physical symptoms. His mind is irritable and depressed, and his 
sleep is usually disturbed with unpleasant dreams. The digestion is 
generally deranged, and the whole appearance may be cachectic. Tre- 
mor may exist, especially in the hands. It is generally not exten- 
sive, consisting ordinarily of slight tremulous movements, which, though 
present when the muscles are at rest, is more distinctly manifested 
when the muscles are put in voluntary action. 

This condition may undergo no further development, but it is often 
the precursory state of the more severe form of the affection. 

In the severe form the symptoms may be manifested by delirium, 
convulsions, or coma, or by any two or all of these phenomena. This 
last was the case in a patient, a master-plumber, in whose case I was 
consulted in the summer of 1873. The attack began with acute deliri- 
um, lasting several days, and then alternating with paroxysms of con- 
vulsions. The seizure ended, after about two weeks, with profound 
coma of forty-eight hours' duration. 

In the delirious form the patient may either present the symptoms 
of acute mania with excitement, or there may be a melancholic condi- 
tion present. In either case there are illusions, hallucinations, and 
delusions. After a variable period a remission generally takes place, 
and this may go on to a complete disappearance of the symptoms, or 
be succeeded by a renewed exacerbation. 

In the convulsive form, the paroxysms may or not be marked by loss 
of consciousness. They may be limited to a particular part of the body, 
as the face, neck, or arms, or they may be general. They may present 
somewhat the characteristics of tetanus or of epilepsy, or of both these 
diseases. In some cases the seizures are not distinguishable from idio- 
pathic epileptic attacks ; the patient has tonic and clonic convulsions, 
froths at the mouth, bites the tongue, may evacuate his urine or faeces, 
and passes into a soporous condition. Or there may be repeated at- 
tacks succeeding each other with such rapidity as to constitute a status 
epilepticus. 

In the comatose variety, the stupor is sometimes developed with 
great suddenness, but is not often so profound as to prevent occasional 
manifestations of partial sensibility. Thus, if the patient be spoken to 
in a loud voice he opens his eyes, or if the skin be pinched he withdraws 
the part or contorts the countenance. 

The pupils are generally dilated and insensible to light, and the 
cheeks and lips are puffed out in expiration. If, in cases in which 
these symptoms occur, the gums be examined, a blue line running 
along their margins will be discovered. Sometimes the whole extent of 
the gums is tinged, but generally the discolored portion is the edge in 



888 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

contact with the teeth, and about a line or at most two lines in width 
Besides the discoloration, the tissue of the gums becomes soft and 
spongy, and it may become absorbed, leaving the roots of the teeth ex- 
posed. All these changes are more marked in the lower than in the 
upper jaw. 

The breath is usually of a peculiar odor, and, if what is called the 
lead-cachexia be present, the complexion is pale, the hair lustreless and 
dry, and the body emaciated. It not unfrequently happens that the 
individuals who suffer from lead-encephalopathy have also been the 
subjects of some one or more of the other manifestations of lead-poi- 
soning. 

b. Lead-Paralysis. — Symptoms. — Before the occurrence of paralysis, 
the patient has probably suffered from attacks of lead-colic, or some 
other affection due to lead-poisoning, though this is not invariably the 
case. The immediately precursory symptoms connected with the loss 
of power are slight numbness and tremors in the muscles of the upper 
extremities. Occasionally, the muscles of the trunk and lower extremi- 
ties become involved in the trembling. 

Ere long the patient observes that he has difficulty in extending the 
fingers or wrist, and that there is a general loss of strength in one or both 
hands. These symptoms go on increasing in severity, and eventually 
he loses the power to raise the hand or fingers. In extreme cases, the 
ability to extend the forearm, or to raise the arm from the side, is lost 
through the paralysis of the triceps and deltoid, or, as in a case before 
my clinique, in January, 1876, the biceps may be paralyzed. Occa- 
sionally the extensors of the lower extremity are involved in the 
paralysis. 

The predominance of the loss of power in the extensors has led to 
the idea that they alone are affected. The dropping of the hand, the 
flexion of the forearm on the arm, the hanging of the arm against the 
side of the body, and, when the lower extremity is affected, the inabil- 
ity to raise the toes so as to avoid striking them against the ground in 
walking, all give countenance to this supposition. But careful obser- 
vation shows that the difference is merely one of degree, and that 
there is a very considerable loss of power in the flexor muscles. In- 
deed, of many cases of the disease that I have observed in hospital 
and private practice, I have never seen one in which the flexors were 
not implicated with the extensors. 

Owing to the disuse of the muscles and to their want of proper nu- 
trition, atrophy takes place, and this is frequently exceedingly well 
marked, and, from the disturbance of the normal equilibrium between 
the several groups of muscles, contractions and distortions ensue. The 
circulation in the affected limbs becomes languid and weak, and pain- 
ful swellings result in consequence. 

It is generally supposed that the right arm is more apt to be 



PLUMBISM. 889 

affected than the left ; such, however, does not appear to be the case. 
Thus, Tanquerel des Planches, 1 of seventy-nine cases in which the 
upper extremities were the seat of the paratysis, found both affected in 
fifty-one, the left twenty-three times, and the right twenty-four. Of 
thirty-two cases of lead-paralysis occurring in my own practice, the 
upper extremities were affected in all ; in twenty-seven both limbs 
were the seat ; and, of the remaining five, three were in the left, and 
two in the right. The left upper extremity was therefore affected 
thirty times, and the right twenty-nine. 

In some cases, the muscles of respiration become very seriously 
paralyzed through the influence of lead, and death then soon takes 
place. In two of my cases there was aphonia, and in several the voice 
was materially weakened. Cases of hemiplegia, the result of lead- 
poisoning, have been observed by Stoll, Andral, and Tanquerel des 
Planches, 

The electric sensibility and contractility are always greatly reduced 
in all cases of lead-paralysis. In the majority of cases, no faradaic cur- 
rent, which it is safe to employ, will produce contractions, and strong 
galvanic currents are necessary. The polar reactions of degeneration 
(page 28) are usually well marked. The cutaneous sensibility is 
rarely impaired. 

The saturnine cachexia is almost always present, and the blue line 
on the gums can readily be distinguished. 

c. Lead- Colic. — This is probably the most common affection caused 
by the toxic influence of lead, and has been recognized from a very 
early period. 

Symptoms. — Lead-colic is particularly characterized by the presence 
of pain, the apparent seat of which is at or near the umbilicus, although 
it may exist at the epigastrium, the hypogastrium, or some other part 
of the abdomen. 

The character of the pain is somewhat peculiar, being a twisting 
sensation of great agony, which appears to revolve around the umbili- 
cus. In some cases the distress of the patient is extreme, and he gives 
utterance to loud cries of anguish, and tosses himself about with the 
utmost violence. Nausea and vomiting are generally present, and the 
bowels are almost invariably constipated. 

The respiration is ordinarily hurried and irregular, but the pulse, 
notwithstanding the physical and mental excitement, remains of its 
normal force, frequency, and rhythm, sometimes becoming markedly 
slower during the height of a paroxysm. 

The abdomen is usually hard and retracted, especially during the 
height of a paroxysm. 

Occasionally the abdomen is painful to the touch, and the suffering 
is aggravated by very slight pressure, but as a rule this is not the case. 
1 " Traite des maladies de plomb," Paris, 1839, tome ii., p. 39. 



890 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

On the contrary, the pain, so far from being increased by pressure, is 
greatly relieved by it, especially if the force be exerted in a uniform 
and gradual manner. Patients often discover this fact for themselves, 
and will lie on the belly or press it with their hands, or beg that others 
will do so. 

The duration of a paroxysm is variable. It may last only a few 
minutes, or may be prolonged for an hour or more. A period of com- 
parative calm then ensues, during which the exhausted patient may 
sleep a little, but his slumber is soon disturbed by another seizure, and 
this sequence may continue for several days.. Paroxysms are more com- 
mon and more severe during the night than the day, and sometimes the 
relation is observed with sidereal punctuality. 

In consequence of the treatment adopted, or spontaneously, the 
series of attacks is broken, and the patient, for the time at least, re- 
covers his ordinary state of health. It is exceedingly rare that death 
ensues from simple, uncomplicated lead-colic. 

d. Lead- Anaesthesia. — Anaesthesia, as a condition due to the toxic 
influence of lead, may exist without complication with other manifes- 
tations, although such an event is not common. In the majority of 
cases it is the optic nerve which is affected, and as a consequence more 
or less complete blindness is produced. Some of the cases formerly 
reported were probably, as Stellwag 1 observes, simply instances of 
ciliary paralysis, but this author admits the existence of an organic 
affection of the nerve, terminating in atrophy, and recognizable by the 
ophthalmoscope. 

Again, the anaesthesia may affect the skin of the trunk or extremi- 
ties, or the muscles of these parts. It is developed generally with great 
rapidity, reaching its height in a few hours. 

e. LeadSypercesthesia. — The pains in the limbs and trunk are 
among the most common of the phenomena of lead-poisoning. The 
lower extremities are generally their seat, and by preference the flex- 
ures of the joints. Thus the groin and the popliteal space are favorite 
situations in the lower limbs ; the axilla and bend of the elbow in the 
upper extremities. The back and thorax are also often affected, and 
sometimes the scalp, face, and neck. 

The pains may be either of a dull aching character, acute, like the 
sensation from the thrust of a sharp instrument, or hot, as if a coal 
of fire were in contact with the part. They occur in paroxysms, and 
are apparently excited by cold, movements, or emotional disturb- 
ance. Occasionally there are spasmodic contractions of the muscles 
of the painful part, either en masse, singly, or in the form of fibrillary 
contractions. 

Like the pains of lead-colic, they are generally relieved by 

1 " A Treatise on the Diseases of the Eye," Hackley and Eoosa's translation, New- 
York, 1868, p. 668. 



PLUMBISM. 891 

steady and gradual pressure, but occasionally this is not the case, 
any kind of touch, light or heavy, causing an aggravation in their 
intensity. 

There is no increased heat of the painful region, no redness or swell- 
ing, and the pulse is generally normal. 

In some cases the pains appear to be seated in the bones ; usually, 
however, the skin and muscles seem to be their situation. 

Causes. — The fact that such affections as those mentioned follow the 
introduction of lead into the system admits of no doubt. This intro- 
duction may take place through the stomach, the air-passages, or the 
skin. The two latter are the more common channels for contamina- 
tion. 

They are, of course, more frequently encountered among those who 
work in lead, such as lead-founders and smelters, the makers of white 
and red lead, painters, plumbers, printers, etc. ; although they may occur 
among those who are only temporarily or accidentally exposed to the 
toxic influence. Thus, they may be caused by drinking water which has 
passed through lead pipes, or been kept in lead vessels, or by using to- 
bacco which has been wrapped in lead-foil. Two cases in which paral- 
ysis was produced by the latter cause have happened in my experience, 1 
and it is so common a cause that, in France, Belgium, and Prussia, 
strong laws have been passed against packing tobacco in lead. The 
use of hair-dyes containing lead is, I think, quite a common cause of 
plumbism. Three cases of paralysis and two of anaesthesia, in which 
this was the cause, have come under my observation, and I am inclined 
to think that a case in which there were vertigo, slight delirium, and 
one epileptic convulsion, owed its origination to the application of lead 
to the hair. 

The employment of powders and enamels to the face is a not infre- 
quent cause of plumbism in women, as most of those substances called 
cosmetics contain lead. Three cases of paralysis and one of pains in 
the body and limbs, caused by lead applied to the face, neck, and arms 
have occurred in my experience. 

The use of plasters and lotions containing lead has also been known 
to give rise to plumbism. 

The majority of cases, however, occur in this country in painters, 
probably for the reason that workers in white and red lead, though 
more exposed, are aware of their danger, and take effectual measures 
to prevent absorption. 

Though the carbonate is probably the most actively poisonous prep- 
aration of lead, it is very certain that all forms — not even excepting 
the sulphate — are capable of producing the characteristic phenomena 
of plumbism. 

1 See my translation of Meyer's "Electricity in its Relations to Practical Medicine," - 
New York, l^O, p. 181, for reference to other cases, 



892 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

* 

Diagnosis. — The history of the case, including a knowledge of the 
occupation of the patient, or of his exposure to the action of lead, wil] 
generally prevent error of diagnosis in regard to any of the manifes- 
tations of plumbism. The presence of the peculiar cachexia and the 
existence of the blue line around the gums will tend still further to ren- 
der the diagnosis accurate. 

Again, it has been ascertained, by the researches of Melsens, that the 
iodide of potassium has the faculty, when taken into the system, of de- 
composing the albuminates with which the lead is united, and of setting 
this substance free. It, then, at once appears in the urine, and can be 
detected by examination with sulphuretted hydrogen. A ready meth- 
od is that proposed by Reeves. A piece of sulphide of potassium is 
inclosed in a piece of thin white linen, and suspended in a vessel con- 
taining the urine suspected to contain the lead set free by the previous 
administration of the iodide of potassium. It is left there for five or 
six minutes. If the urine contains any salt of lead, it is decomposed, 
and the metal is deposited on the linen in the form of the sulphuret, 
staining it of a dark, almost black, color. 

As regards the several affections separately, it is to be remarked 
that most difficulty will be experienced relatively to the encephalopathy 
produced by lead. Jaccoud 3 has pointed out that in the condition of 
the bodily temperature we have an additional point toward discrimi- 
nating between acute cerebro-spinal meningitis and the affection under 
notice. In the former the temperature rises to 104° Fahr., or even 
higher, while in the latter there is no augmentation, or at least a very 
slight rise. 

In lead-paralysis the fact that the loss of power mainly affects the 
extensors, especially those of the hand, together with the antecedents 
of the patient, and the presence of other evidence of plumbism, will 
generally suffice to render the diagnosis certain. I have recently, how- 
ever, had a case at my clinique at the University Medical College, in 
which there was some doubt. The patient had paralysis of the exten- 
sors of both wrists. Several weeks before its appearance he had broken 
his ankle, and had been obliged to walk on crutches. There was, there- 
fore, a question as to whether the case was one of " crutch-paralysis," 
from pressure, or of lead-paralysis. The man was a laborer, and had 
never, to his knowledge, been exposed to lead in any way. But the 
facts that there was no anaesthesia, that the paralysis was greatly pre- 
dominant in the extensors, and that the muscles of the arm above the 
elbow were not affected, decided me in concluding that the case was 
not one resulting from pressure on the brachial plexus. The further 
fact that there was a slight blue line visible along the gums convinced 
me that, notwithstanding the absence of any history of contamination by 
lead, the case was one of that disease. The patient was a beer-drinker, 
1 " Lecons de clinique medicale," Paris, 1869, p. 492. 



PLUMBISM. 893 

and might, I conceived, have become poisoned in that way, as had 
others in my experience. 

In lead-colic the character of the pain and its situation may be of 
service in the formation of a diagnosis, but the main reliance must be 
upon the antecedents of the patient, and the coexisting evidences of 
plumbism to which attention has already been directed. 

These circumstances are likewise what must govern us in lead-anaes- 
thesia and hyperesthesia. 

Prognosis. — This is not unfavorable except as regards the cerebral 
manifestations, provided the patient can be submitted to proper treat- 
ment and removed from all exposure to lead-poisoning. Lead-encepha- 
lopathy is the most serious of all the forms of plumbism, and this is es- 
pecially the case when there is a combination of delirium, convulsions, 
and coma. Of seventy-two cases observed by Tanquerel des Planches, 
sixteen were fatal. It was probably more apt to terminate in death in 
his day than now, when the hygienic and therapeutical relations of 
plumbism are better understood. Recovery ensued in all of the cases 
occurring in my experience. 

In lead-paralysis the prospect of recovery depends altogether on the 
ability to produce contractions in the paralyzed muscles by electricity. 
If the induced current will effect them, the cure will be rapid ; if the 
interrupted primary current is required, a longer time must elapse be- 
fore success is attained ; but, if the muscles will not react to either the 
induced or primary currents, a favorable result is not to be expected. 
The extent of the atrophy is also an important element in the prog- 
nosis. 

In lead-colic, hyperesthesia, and anaesthesia, the prospect of recov- 
ery is good, provided the necessary hygienic and therapeutical indica- 
■ tions can be fulfilled. 

Morbid Anatomy and Pathology. — Very little is known relative to 
the morbid anatomy of plumbic affections. In the several forms with 
which we are acquainted, the nervous system rarely presents evidences 
of any lesion which can be regarded as characteristic. In some cases of 
lead-encephalopathy, however, there has been found a flattened, indu- 
rated, and atrophied condition of the brain, and in others the indica- 
tions of inflammation and softening. 

In the case of a painter who had suffered from repeated attacks of 
lead-colic, and who finally died with head-symptoms — delirium, epi- 
lepsy — reported by MM. Gueneau de Mussy and Lemaire, the post- 
mortem examination showed the existence of a large extravasation, 
which had broken through the cerebral tissue from the circumference 
to the fourth ventricle. 

Gombault 1 recently reported a case of lead-paralysis in which, on 
1 Archives de physiologic, lS^. 



894 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

post-mortem examination, the spinal cord and the nerve-roots were 
found to be unaltered, but in some of the peripheral nerves the medul- 
lary substance was separated into granules, though the axis-cylinder 
was normal. 

Westphal 1 has discovered, in a case of lead-paralysis, a similar con- 
dition of the radial nerve. In this case the spinal cord and the nerve- 
roots were unchanged. 

In a case of lead-poisoning in which there had been, during life, colic, 
vomiting, diarrhoea, and finally collapse, Kussmaul and Maier a found 
sclerosis of the cceliac and superior cervical ganglia of the sympathetic 
and periarteritis in the brain and spinal cord. 

Lead has been detected, in cases of plumbism, in the tissue of the 
brain, spinal cord, and nerves. In fact, it appears to have a special 
affinity for the nerve-substance. 

It is probable that, except in extreme cases, or in very exceptional 
instances, the changes in the brain, spinal cord, nerves, and sympa- 
thetic system are not such as are discoverable by our present means of 
research, just as are the alterations produced by opium, alcohol, hydro- 
cyanic acid, strychnia, and other substances. 

The muscles, in cases of lead-paralysis, have been examined by An- 
tral, 3 Gendrin, 4 Tanquerel des Planches, 5 and others, and analogous 
results obtained. The fibres have been found to be pale and yellowish, 
to be friable, atrophied, and desiccated. I have repeatedly removed 
small portions with Duchenne's trocar, and have always found the 
transverse striae disappearing, and fatty degeneration making its ap- 
pearance. 

The hypothesis that the affection is, primarily, one of the muscles, 
is not supported by facts ; those cases of apparent loss of muscular 
irritability, resulting from certain poisons, adduced by Longet, 
Bernard, Mitchell, myself, and others, were simply instances in 
which the loss of nervous irritability took place from the periphery to 
the centre. 

Facts, too, are against the notion that the lead acts by contact with 
the muscles, and the circumstance of the paralysis occurring so gener- 
ally in the hands of painters, for instance, is adduced in proof. But we 
have seen that the left hand is just as frequently affected as the right, 
while it is certainly less in contact with the lead. Moreover, those 
cases of paralysis in the extensors of the hand which have resulted 
from hair-dyes and other cosmetics, are altogether against the hypothe- 
sis in question. 

1 Ardiiv fur PsycJiiatrie, Band iv., ]874. 

2 Dcutsehes Arclxiv fur klin. Med., Band ix., H. 2. 

3 " Clinique Medicale," tome ii., p. 227. 

4 " Maladies de l'encephale," par Abercrombie, traduction, second edition, p. 576. 

5 Op. cit., pp. 77, 144, 149. 



PLUMBISM. 895 

In casss of lead-colic there appear to be no anatomical changes in 
the intestines which can be reasonably associated with the phenomena 
of the disease as their cause. 

Treatment. — In the treatment of plumbism there are certain princi- 
ples to be acted upon in all the affections embraced within its limits. 
One of these, the prophylaxis, belongs to the domain of hygiene, and 
therefore need not be here considered; the other, the removal of the 
lead from the system, demands our first care. 

The researches of Melsens have shown that in the iodide of potas- 
sium we have an agent which separates the lead contained in the tis- 
sues from its combinations, and forms with it an iodide of lead, under 
which form it is excreted from the organism by the kidneys. 

Some authors advise caution in the use of the iodide of potassium, 
on the ground that the resulting compound is very poisonous, and may 
produce highly-deleterious effects. In a great many cases of lead-pa- 
ralysis and other consequences of lead-poisoning in which I have given 
the iodide, I have never seen the least untoward result, and I always 
use it in large doses from the beginning. In many cases the lead can 
be readily detected in the urine, and the blue line around the gums 
disappears quickly under its use. If there is great debility, or if the 
cachexia be marked, iron, quinine, and strychnia, may be employed with 
advantage. 

In the treatment of lead-encephalopathy, the free administration of 
the iodide of potassium combined with the bromide affords the best 
prospect of success. 

In attacks of lead-colic, the hypodermic injection of morphia, in 
doses sufficient to keep the pain in check while the iodide of potassium 
is doing its work, with an occasional purgative, will generally be all the 
treatment required. 

But in lead-paralysis the loss of power remains, and would continue 
indefinitely, without the use of measures directed specially against it : 
chief among these is electricity. The faradaic current, if it will cause 
the muscles to contract, is to be preferred. Each paralyzed muscle 
must be acted on for two or three minutes every day, so that for both 
upper extremities the duration of a seance would vary from a half to 
three-quarters of an hour. In ordinary cases two months will suffice 
to effect a cure. 

But it often happens that the electric contractility of the para- 
lyzed muscles is so completely abolished that the faradaic current 
is without effect. In such cases the interrupted galvanic current 
must be used, and continued till, as will eventually be the case, the 
faradaic current causes contractions. I have never seen a case in 
which the galvanic current would not produce contractions. One of 
the worst examples of the affection in question I ever saw was the 
patient who formed the subject of a clinical lecture to the class at the 



896 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

Bellevue Hospital Medical College. 1 His improvement under the 
circumstances was rapid, and he eventually was able to earn his liv- 
ing again. Faradaic currents of great power failed to produce con- 
tractions, and but for the use of the galvanic current he would have 
been incurable. 

If the galvanic current fails to act on the muscles, success is out of 
the question. 

In addition to electricity, frictions, kneading the muscles, and pas- 
sive exercise, are useful. Contractions may be overcome by suitable 
prothetic apparatus. 

In a case under the care of Prof. Sayre, and which I had the 
opportunity of seeing, the patient, a young lady, was able to play the 
piano — though paralyzed in both hands — by means of an admirable 
appliance devised by Dr. E. D. Hudson, of this city. 

In the treatment of lead-ansesthesia and hyperesthesia, the iodide 
of potassium conjoined with the use of the galvanic or faradaic cur- 
rent to the affected parts will generally prove sufficient to effect a cure. 



CHAPTER II. 

ALCOHOLISM. 

Alcoholism — under which term I do not now propose to embrace 
the condition called drunkenness, the immediate result of the ingestion 
of a large quantity of alcohol— is exhibited under two somewhat differ- 
ent forms. One of them is the permanent state which exists in persons 
who habitually imbibe excessive amounts of alcohol, and is known as 
chronic alcoholic intoxication or chronic alcoholism. The other is a 
paroxysm, the result of still greater excess, or the sudden stoppage of 
the stimulus to which the system has become habituated, and is desig- 
nated by various names, such as delirium tremens, mania apotu, or 
more properly acute alcoholism. 

a. Chronic Alcoholism. — The attention of the medical profession 
was first prominently directed to the subject of chronic alcoholism by 
Dr. Magnus Huss, 2 of Stockholm, in 1849. In my description of the 

1 Journal of Psychological Medicine, January, 1871, p. 43. 

2 Dr. Huss's work, being printed in Swedish, is to a great extent unread outside of Scan- 
dinavia. Two very excellent articles, embracing a full synopsis of his work, were pub- 
lished in the British and Foreign Medico- Chirurgical Review, in 1851 and 1852. I shall 
also draw largely from an address on " The Effects of Alcohol upon the Nervous System," 
which I delivered May 4, 1874, on assuming the presidency of the New York Neurological 
Society, and which was published in the Psychological and Medico-Leg aljournal, for July, 
1874. 



ALCOHOLISM. 897 

disorder, I shall, to a great extent, avail myself of his thorough obser- 
vations. 

Symptoms. — In one group of cases resulting from the long use of 
intoxicating liquors, the principal manifestations of the disease relate to 
the muscular system. Tremor and unsteadiness, especially of the up- 
per extremities, are among the first symptoms. Subsequently the lower 
limbs are affected, and then the muscles of the trunk. These phenom- 
ena are most marked in the morning, before the patient has had his 
accustomed dram. 

In other cases the tremor is not a very prominent feature, though, 
as far as my experience goes — and it is by no means inconsiderable — 
no patient with the disorder in question is free from a tremulous agita- 
tion of his muscles when he attempts to make a voluntary movement. 
But it may not be well marked, and, instead of it, the individual observes 
that he cannot hold things as well as he once did. Objects which he 
takes hold of fall from his hands without his being able to retain them. 
If he does exert himself to avoid this inconvenience, the hands are 
seized with an involuntary trembling, which he calls "nervousness," 
and which he endeavors to cure by fresh potations. From this feeble- 
ness or paresis the distance to paralysis is not great. 

I had, not long ago, a case under my charge in which the patient, a 
gentleman of admitted eminence in his profession, clearly suffering from 
chronic alcoholism, could hold nothing in his hands unless he kept hia 
eyes fixed upon them. The moment he ceased to look, the object fell 
to the ground. In the present treatise I have referred to several in- 
stances of this curious condition which were due to other causes. 

The tower extremities eventually become affected, and the patient 
may entirely lose the power of locomotion. The nerves of sensation 
also become involved, and there are various abnormal feelings, consti- 
tuting one or more of the forms of anaesthesia. Vertigo and dimness 
of vision may also be present. 

This type of the disease Dr. Huss calls the paralytic. 

In the next form, or the anaesthetic, the phenomena are more di- 
rectly connected with perverted or lost sensibility from the outset. The 
extremities first become affected, and subsequently the central parts of 
the body. In the beginning the patient experiences a difficulty in de- 
termining from the feel the nature of the object he has laid hold of, or 
against which his foot may have struck. But in a more advanced stage 
he loses all sense of pain, and pins may be thrust into his skin, or a coal 
of fire dropped upon it without his experiencing any discomfort. With 
the anaesthesia there is always loss of motor power. 

The aesthesiometer, the application of which instrument to practical 
medicine is of more recent date than Dr. Huss's observations, enables 
us to detect incipient loss of sensibility at a very early stage of the 
affection. 

68 



898 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

Symptoms connected with this category of cases which I have no- 
ticed, but which are not alluded to by Dr. Huss, are that the senses of 
sight, hearing, smell, and taste, are also often involved. 

Another singular phenomenon which I have observed in these cases, 
which is referred to by Magnan, 1 and also quite recently by Virenque, 2 
is that the loss of sensation involves only one lateral half of the body. 
This hemi-ansesthesia is met with in several other morbid conditions, 
notably as we have seen in hysteria. The other special senses are gen- 
erally implicated. Thus the patient loses the sight of one eye ; cannot 
hear with one ear ; can taste the most strongly sapid substances with 
only one half of the tongue, and perceive the most penetrating odors 
with only one nostril. In one case cited by Magnan, the patient, who 
had long been addicted to the excessive use of alcoholic liquors, and 
subsequently to the use of absinthe, had hallucinations and delusions in 
addition to the hemi-anassthesia, and, what is unusual, complete loss of 
sensation in the cornea of one eye, although tears were excited in both 
eyes when the affected one was touched by the finger. 

In the third form of chronic alcoholism, convulsions constitute a 
prominent feature, though they are not generally among the first symp- 
toms. I have, however, witnessed several cases in which epileptiform 
seizures were the immediate and direct consequence of the excessive 
use of alcoholic liquors, and in which there had been no well-marked 
premonitory symptoms. But in the great majority of instances there 
are derangements of motility and of sensibility, such as have just been 
described, and then the gradual supervention of convulsive jerkings of 
the muscles, similar to those which occur in convulsive tremor and 
chorea, combined with painful tonic contractions or cramps. After a 
time the spasms are accompanied with loss of consciousness, and hence 
are more truly epileptic in character. Dr. Huss noticed that as the 
condition of chronic alcoholism became more profound there was a ten- 
dency toward the disappearance of the convulsions, and that at last 
they ceased entirely. 

In the next and last variety of the affection there is a general hyper- 
aesthetic condition of the skin and other special organs of the senses. 
The least touch causes intense pain ; bright lights are unendurable, 
and even the diffused light of a moderately illuminated room is pain- 
ful. Very gentle noises cause great discomfort, and loud sounds are 
agonizing. Even the smell and taste are exaggerated, and occasionally 
perverted to the extent of illusions. 

In whatever form chronic alcoholic intoxication may manifest itself, 
there are occasionally notable symptoms present which do not con- 

1 " De l'alcoolisnie, des diverses formes, du delire alcoolique et de leur traitemeut," 
Paris, 1874. 

2 "De la perte de la sensibilite generale et speciale d'un cote du corps," etc., Paris. 
1874. 



ALCOHOLISM. 899 

stitute ordinary features of the disease. Thus there may be double 
vision, from paralysis of one of the ocular muscles, usually the internal 
rectus, in which case there is ptosis also ; or the muscles concerned in 
articulation are involved, and speech becomes imperfect or impossible ; 
or those by which swallowing is effected are paralyzed, or there is vio- 
lent palpitation of the heart, or intense neuralgic pain in one or more 
parts of the body. To touch on all these complications would require 
more space than I have at my disposal. But the mental symptoms 
which form more or less prominent characteristics of all cases of chronic 
alcoholism require a somewhat extended notice. The perceptions, the 
emotions, the intellect, and the will, are all implicated to a greater or less 
extent. Attention has already been called to the aberrations of the 
perceptions constituting illusions and hallucinations. The emotions 
assume an undue prominence, especially those of a sorrowful character, 
and thus the individual becomes maudlin, a condition which I should 
describe as consisting in a disposition to lament and shed tears over 
imaginary or greatly exaggerated griefs. It is rarely the case in my 
experience that the subject of chronic alcoholism is changed from a 
peaceable to a quarrelsome person, or from a timid to a brave one. 
The alteration is almost always in the other direction. At the same 
time it is not to be denied that individuals, whose passions are vicious 
and not held in complete subjection, are rendered still more vicious and 
uncontrollable by* chronic alcoholism. Perhaps the most characteristic 
feature, as regards the emotions which persons suffering from the dis- 
ease in question exhibit, is irritability of temper. This is shown in the 
fact that slight circumstances, which in a state of health would cause 
no annoyance, now give rise to great vexation. At the same time, 
though there is not, as I have said, much tendency to quarrelsomeness, 
there is nevertheless a proneness to take offense, and to regard, as 
slights and insults, acts which have no bearing in that direction. 

Again, there is intense melancholy, without the existence of delu- 
sions, and during which the individual may attempt suicide ; or there 
may be indefinable fear, despair, terror, or shame, leading to the perpe- 
tration of self-destruction. 

The more purely intellectual qualities of the mind rarely escape 
being involved in the general disturbance. The power of application, 
of appreciating the bearing of facts, of drawing distinctions, of exercis- 
ing the judgment aright, and even of comprehension, are all more or less 
impaired. The sense of right and justice which the individual may have 
had is so weakened or destroyed that he will lie, steal, murder, or com- 
mit other outrages, even when there is no provocation. Indeed, the 
existence of motive is generally a counteracting circumstance. 

The memory is among the first faculties to suffer. 

But in addition to these evidences of mental deterioration there may 
be actual aberration of mind, as shown by the existence of delusions. 



900 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

These are generally of a depressing character, and may or may not have 
their origin in false perceptions of the senses. These delusions may 
prompt to suicide or other act of violence. 

The will is always lessened in force and activity. The ability to 
determine between two or more alternatives, to resolve to act when 
action is necessary, no longer exists in full power, and the individual 
becomes vacillating, uncertain, the prey to his various passions, and to 
the influence of vicious counsels. 

"With these troubles of the mind there are almost invariably head- 
ache, vertigo, and persistent wakefulness, all of which give evidence of 
the extent to which the nervous system is affected. 

All writers of systematic treatises upon insanity have called atten- 
tion to the frequency with which mental aberration is caused by the 
excessive use of alcoholic liquors, but, in a recent monograph, M. Mar- 
faing * has given some interesting data relative to the characteristics of 
the insanity produced by alcoholism. Thus, he has observed that the 
hallucinations and delusions are almost always of a painful character. 
The patient sees frightful or repulsive objects, armed men or horrible 
animals; he sees persons lying in wait for him, or a thousand obstacles 
are interposed between him and his desires; he hears menacing voices, 
and the supplications of his friends for help from dangers which en- 
compass them. 

Occasionally, however, the imaginings are of a more pleasant char- 
acter. He is surrounded with flowers and fountains ; beautiful women 
are his companions, and, though his generative power may be entirely 
extinct, he brags of his conquests, and the favors which are showered 
upon him. 

Another characteristic of the hallucinations and delusions of the 
mania of alcoholism is, their changeability. Scarcely has he expressed 
one delirious conception when another is uttered, and so on for days at 
a time. 

A somewhat peculiar variety of chronic alcoholism is that produced 
by the drinking of absinthe, a habit which prevails to a great extent in 
France, and which, though barely naturalized in this country, has a 
large and increasing number of votaries. 

The condition in question has been well studied by M. Magnan 2 by 
experiments on the lower animals as well as by observations in man. 
The main fact appears to be that absinthe has an especial proclivity to 
produce epileptic convulsions, in addition to causing the other phenom- 
ena due to the highly-concentrated alcohol it contains. 

Death may ensue in chronic alcoholism, from the accompanying 

1 "De Palcoolisme considere dans ses rapports avec l'alienation mentale," Paris, 
1875. 

2 "Etude experimentale et clinique sur l'alcoolisme," Paris, 1871; also "Dp l'alcoo- 
lisme," Paris, 1874. 



ALCOHOLISM. 901 

morbid conditions, induced in the brain or other parts of the nervous 
system ; from exhaustion, owing to the direct effects of the poison, or to 
the inability of the stomach to digest, and the assimilative organs to ap- 
propriate the food taken ; or, as is commonly the case, from the super- 
vention of some intercurrent affection to which, owing to the depressed 
condition of the system, the patient is particularly liable. 

b. Acute Alcoholic Intoxication, Delirium Tremens. Symptoms. — 
Among the first symptoms of acute alcoholism, gastric and intestinal 
derangements are to be noticed. Thus there are anorexia, nausea, and 
vomiting, especially in the morning, and either diarrhoea or obstinate 
constipation, and the tongue is furred and dry. The pulse is usually 
rapid and feeble, the skin cold and clammy, and the general powers of 
the system much reduced. The sleep is deficient in amount and is dis- 
turbed by frightful dreams, and there are often vertigo, headache, and 
confusion of ideas. 

At a very early period tremor is present, and is especially manifested 
in the tongue, which, when protruded from the mouth, cannot be held 
steady, and the continual action of which is further shown in the de- 
fective articulation which always exists. The upper extremities and 
sometimes the head are also the seat of tremulous movements. 

These symptoms gradually increase in intensity, and other phenom- 
ena are soon developed. The countenance assumes a wild expression, 
the manner becomes hurried and anxious, the illusions, hallucinations, 
and delusions, become more vivid, and they are almost invariably of a 
terrifying character. Frightful objects, such as reptiles, demons, and 
other horrible figures, are perceived, and the patient covers his head in 
the bedclothes in the vain endeavor to shut out the sight of them, 
or may even commit suicide in the effort to escape from the imaginary 
dangers which threaten him. Hallucinations of the other senses are 
also sometimes present. The temper becomes still more irritable, and 
the motility is increased to an extreme degree. Sleep is no longer pos- 
sible, and day and night the visions and delusions are ever present in 
some form or other. The body becomes hot, but the extremities still 
remain cold and clammy. The pulse ranges from 100 to 120 or more, 
and is small and weak. The urine is scanty and high-colored, the bow- 
els constipated. 

During all this period the patient talks incessantly, generally with 
reference to his hallucinations and delusions. These latter, though well 
marked, and constant, are, like his erroneous perceptions, changeable ; 
and it rarely happens that they cannot, for the moment at least, be 
dissipated by a few words from those around, 

The pupils are usually strongly contracted, and if the fundus of the 
eye be examined with the ophthalmoscope, the disk and retina will be 
found congested. Dr. Clifford Allbutt J states that he makes it a rule 

1 " On the Use of the Ophthalmoscope in Diseases of the Nervous System," London 
and New York, 1871, p. 258. 



902 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

to examine the fundus in all cases of delirium tremens which come un- 
der his observation, and that in the great majority of cases he finds 
congestion and opalescence of the disk, and full retinal veins. 

In some cases — especially in those which are the direct result of the 
excessive use of alcoholic liquors, and not the consequence of a sudden 
deprivation of an accustomed stimulus — convulsions of an epileptiform 
character may occur ; usually these are repeated again and again. 
Death may take place during their continuance, and they always add 
greatly to the gravity of the situation. 

An attack of acute alcoholism lasts ordinarily for from three to five 
days. If recovery is to ensue the patient obtains a little sleep, and 
awakes with a decided mitigation in the violence of all his symptoms. 
If, on the contrary, death is to result, his physical powers become rap- 
idly exhausted, the delirium becomes low and muttering, he picks at 
the bedclothes, he passes into a state of coma, the pulse rises still higher 
in frequency, while it becomes correspondingly weaker, the bodily tem- 
perature falls, and he gradually sinks or dies from a renewal of the con- 
vulsive seizures. 

Causes. — Though the abuse of alcohol as a beverage is the essential 
cause of alcoholism, chronic or acute, it is not to be supposed that these 
conditions are induced in all persons who use alcoholic liquors to ex- 
cess. Some individuals are not only able to indulge to an extreme 
degree with impunity, but may even live to old age in the enjoyment 
of apparent good health. Indeed, when Huss published the results of 
his observations, it was strongly questioned whether the sjmiptoms 
which he had noticed were not due to the impurities which the whiskey 
generally used by the lower classes in Sweden is known to contain, rather 
than to alcohol. Huss admits that since liquor made from potatoes 
came into use, and especially since it has been distilled from rotten po- 
tatoes, chronic alcoholism has become much more frequent. This was 
attributed to the fusel-oil and a peculiar substance called stick / but it 
was ascertained that, though these substances may have aggravated the 
symptoms, they were, in the main, produced by the alcohol. Many 
will doubtless call to mind that in this country a like charge has been 
made against fusel-oil, and that even strychnia has had the reputation 
of poisoning whiskey and inducing most of the evil effects of exces- 
sive alcoholic potations. 

It is very certain, however, that alcoholic intoxication very rarely, 
if ever, ensues on the moderate use of the light German or French 
wines, or of those made in this country, when they are not fortified by 
the subsequent addition of spirit, and that it is still less apt to occur 
from the temperate use of malt liquors. 

In those countries in which wine or beer is the chief alcoholic bev- 
erage, the peculiar conditions which have been described are rarely met 
with. Thus Niemeyer omitted from the earlier editions of his work on 



ALCOHOLISM. 903 

the " Practice of Medicine " all reference to either chronic or acute alco- 
holism, and a chapter was afterward specially added in order to render 
the work more useful to American and English physicians, for whom it 
was translated by Dr. C. E. Hackley, of this city. In France, also, be- 
fore the recent increase in the consumption of the stronger alcoholic 
liquors and absinthe, neither form of the affection under notice had 
attracted much attention. Marfaing begins his monograph, to which 
reference has already been made, with the statement that previous to 
the last twenty-five years alcoholism was hardly known. But in the 
northern European countries, in Great Britain,, and in the United States, 
where whiskey, gin, rum, and brandy, have been the more common forms 
under which alcohol has been ingested, delirium tremens has always 
been a prominent disease, and the chronic form doubtless existed long 
before Huss pointed out the features by which it was to be recognized. 

It appears, therefore, that what are called the spirituous liquors are 
more powerful in causing alcoholism than either the malt or vinous. 
This is probably due to the facts that more alcohol is imbibed with the 
former than the latter, more than can promptly be eliminated, and that, 
owing to its concentrated form, greater derangement of the tissues, 
with which it comes in contact, is produced. It is thus with alcohol as 
with all other powerful agents taken into the system. 

That acute alcoholism or delirium tremens results directly from the 
excessive ingestion of alcohol is admitted by all writers on the subject, 
but they are not so generally agreed that it may ensue indirectly from 
such excessive use, by the individual being suddenly deprived of the ac- 
customed stimulus. Thus Aitken a denies in very positive terms that 
delirium tremens may occur as a consequence of cessation from drink- 
ing, but to my mind any one who has seen the disease in soldiers, sail- 
ors, or prisoners, will be slow to confirm his statements. I have fre- 
quently seen delirium tremens occur in soldiers whose debauches have 
been suddenly interrupted by confinement in the guard-house, and I am 
quite sure that most army, and navy, and prison medical officers have had 
similar experience. Watson, a on the other hand, assigns no other cause 
than that the " habitual stimulus has been diminished or abandoned ; " 
but he subsequently, without seeming to notice the bearing of the case, 
refers to an instance in which the patient was constantly under the influ- 
ence of alcoholic liquor. Dr. Flint, 3 however, distinctly recognizes this 
dual causation, but the fact does not appear to influence his views 01 
pathology or treatment. 

1 " The Science and Practice of Medicine," third American edition, vol. ii., p. 847, 
Philadelphia, 1872. 

8 ''Lectures on the Principles and Practice of Physic," American edition, Philadel- 
phia, 1872, vol. i., p. 347. 

3 u^ Treatise on the Principles and Practice of Medicine," third edition, Philadel 
phia, 1868, p. 735. 



904 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

The one form occurs at the height of an alcoholic debauch ; the 
other results when the system, habituated to large and repeated doses 
of alcohol, is suddenly deprived of a stimulus to which it has become 
thoroughly habituated. We see a like condition induced in those who, 
having become accustomed to the ingestion of opium, suddenly or too 
rapidly leave off the use of the drug. 

In their therapeutical relations the distinction between these two 
modes of causation is, as we shall hereafter see, important. 

Diagnosis. — The clinical history as well as the peculiar symptoms 
will prevent any mistake being made relative to the real character of a 
case of alcoholic intoxication, either chronic or acute. 

Prognosis. — The chronic form is generally successfully treated if the 
patient can be made to abstain from the further use of alcohol. A 
paroxysm of the acute form is also usually recovered from, provided 
there have not been many previous attacks. The occurrence of con- 
vulsions is, however, a serious complication, and almost invariably cases 
in which they take place terminate fatally. If the patient abstains 
from the further excessive use of alcohol, it is not at all probable that 
other attacks will ensue. 

Of course, these remarks refer to alcoholism, and not to the lesions 
in the stomach, liver, intestines, heart, and other organs, which may 
have resulted from the abuse of alcoholic liquors, but which are not 
directly connected with the nervous system. 

Morbid Anatomy and Pathology. — The most common patho-ana- 

tomical condition of the nervous system met with in cases of alcoholism, 
chronic or acute, is congestion of the cerebral meninges and of the sub- 
stance of the brain. This alteration is especially liable to affect the 
vertical surface. An effusion of serum is a general concomitant, partic- 
ularly in the acute form of the disease — and this may be either in the 
subarachnoid space or in the ventricles. At a later period, if the ex- 
cesses be continued, the dura mater may become chronically congested, 
and eventually pachymeningitis and hsematoma are developed. 

Or the repeated or continual congestion of the pia mater and 
arachnoid may result in the production of a chronic inflammatory pro- 
cess, attended with thickening and opalescence of these membranes. 
The vessels, especially the veins, are gorged with blood, and there may 
be various morbid products, such as serum, pus, or sero-pus effused. 

The brain, however, presents the most characteristic alterations. 
These appear to be the result of irritation and degeneration, the latter 
process consisting of a granular or fatty disintegration of the cerebral 
tissue, generally most marked in the cortical substance. 

Dr. John 0. Peters, 1 of New York, was among the first to make 
careful and systematic observations of the post-mortem appearance of 

1 " On the Pathological Effects of Alcohol," New York Journal of Medicine, vol. iii., 
1814, p. 335. 



ALCOHOLISM. 905 

individuals who had died from the excessive use of ardent spirits. As 
regards the brain, he found that " invariably there was present more or 
less congestion of the scalp and of the membranes of the brain, with 
considerable serous effusion under the arachnoid, while the substance of 
the brain was unusually white and firm, as if it had lain in alcohol for 
an hour or two, and the ventricles were quite empty. In not more than 
eight or ten instances did we find more red spots upon the cut surface 
of the brain than usual. The peculiar firmness of the brain was noticed 
several times, even when decomposition of the rest of the body had 
made considerable advance." 

Such changes as are described cannot result entirely from conges- 
tion, but must be ascribed, in great part, to the direct action by contact 
of alcohol on the brain-substance. It will presently be shown how 
strong is the affinity of alcohol for this tissue. As Carpenter x remarks, 
alcohol passes into the brain and changes both its chemical and physi- 
cal properties. It would be strange indeed, therefore, if with alteration 
of structure there were not also aberrations of function. 

The experiments of Dr. Percy a have often been brought forward as 
proving something in regard to alcohol which was not true of any other 
substance. This observer injected strong alcohol into the stomachs of 
dogs. The quantity varied from two to six ounces. Death followed, 
and upon examining the blood and brain for alcohol it was always 
found. The presence of alcohol in the blood and brain, to those who 
look superficially or ignorantly at the matter, has rather a horrible 
aspect ; but when we know that there is no substance capable of being 
absorbed by the stomach and intestines which cannot also, by proper 
means, be detected in the blood and viscera, the subject loses much of 
its striking character. Dr. Percy used alcohol of 850° specific gravity, 
which represents a mixture containing about eighty per cent, of absolute 
alcohol. As the strongest brandy and whiskey contain but about fifty- 
four per cent, of alcohol, the concentrated character of the liquor used 
by Dr. Percy is at once seen. In one case six ounces were injected into 
the stomach of a dog, a quantity amply sufficient to cause death in an 
adult man. 

Many other physiologists have detected alcohol in the blood and 
viscera of animals after its ingestion into the stomach. 

I have several times performed experiments with reference to this 
point, and have never failed to recognize the presence of alcohol in the 
blood, brain, the stomach, expired air, and urine of dogs to which I had 
administered strong alcohol ; but, when using liquors containing from 
sight to fifteen per cent, of alcohol, such as the German, French, and 

1 " On the Use and Abuse of Alcoholic Liquors in Health and Disease," London, 1870. 
9 " An Experimental Inquiry concerning the Presence of Alcohol in the Ventricles o/ 
the Brain," etc., London, 1839. 



906 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

Spanish wines, I have never been able to find it in the solids, though 
detecting it readily in the products of respiration. 

It is not to be doubted, therefore, that alcohol, like other sub- 
stances, is absorbed into the blood, and exerts its influence on the sys- 
tem through the medium of this fluid. 

Pure alcohol is a violent poison. In the dose of less than one ounce 
I have seen it cause death in a medium-sized dog, and many cases are 
on record of fatal effects being immediately produced in the human 
subject after comparatively small quantities have been swallowed. 
When diluted, its effects are not so rapidly manifested, and from this 
form, when taken in sufficient quantity, the condition known as intoxi- 
cation is produced. Previous to this point being reached the nervous 
and circulatory systems become excited, the mental faculties are more 
active, the heart beats fuller and more rapidly, the face becomes 
flushed, and the senses are rendered more acute in their operation. If 
now the further ingestion be stopped, the organism soon returns to its 
former condition, without any feeling of depression being experienced ; 
but, if the potations are continued, the complete command of the facul- 
ties is lost, and a condition of temporary insanity is produced. If 
further quantities be imbibed, a state of prostration, marked by coma 
and complete abolition of the power of sensation and motion, follows. 
Such is a brief outline of the obvious symptoms which ensue upon the 
use of alcoholic liquors in considerable quantities. When taken in 
amounts less than are sufficient to induce any marked effect upon the 
circulatory and nervous systems, there is, nevertheless, an influence 
which is felt by the individual, and which is mildly excitatory of the 
mental and intellectual faculties. 

The very important physiological relations of alcohol scarcely come 
within the scope of this treatise ; but the pathological conditions which 
result from it are of importance in the present connection, and may 
therefore profitably engage a share of our attention. 

The general action of a large dose of this substance is shown in the 
following experiment : 

I caused a dog to take into its stomach three ounces of strong alco- 
hol, diluted with a corresponding quantity of water. Immediately on 
receiving it, the animal retired to a corner of the room and lay down. 
At the end of five minutes I endeavored to make it walk about the 
apartment, but it did so with evident reluctance, though up to this 
time the gait was not staggering. I should have stated that I detected 
alcohol in the expired air in forty-eight seconds after administering the 
liquid. 

After eight minutes the dog walked with some difficulty, and on 
carefully examining the gait I found that the posterior extremities were 
beginning to be paralyzed. This paralysis gradually increased, the gait 
became more and more staggering, and at the end of fourteen minutes 



ALCOHOLISM. 907 

the animal could no longer stand. The paralysis had now reached the 
anterior extremities. 

Sensibility was still present, though evidently lessened in acuteness ; 
loud noises were perceived, and the eyes were involuntarily closed when 
the motion of striking was made before them. The respiration was 
hurried, and the action of the heart was greatly accelerated. 

The pupils were at first contracted, but became dilated in about fif- 
teen minutes, and remained in that condition throughout the experiment. 

In thirty minutes the animal was in a state of profound coma. Sensi- 
bility, even of the cornea, was abolished; the limbs were in a state of com- 
plete resolution; the respiration was hurried; the heart beat rapidly but 
feebly ; the urine and fasces passed involuntarily, and the temperature, 
as indicated by a thermometer placed in the rectum, had fallen from 101° 
Fahr., which it was before the ingestion of the alcohol, to 98.5° Fahr. 

The animal remained in a comatose condition, and died one hour 
and twenty-two minutes after the ingestion of the alcohol. 

In this experiment the alcohol was administered in such a large dose 
that the period of excitation, which generally follows in a few minutes, 
was masked or altogether prevented. In the following experiment, the 
quantity was smaller, and the sequence of phenomena was more regular. 

I introduced into the stomach of a large dog one ounce of alcohol, 
diluted as before. 

Nothing occurred worthy of notice during the first five minutes. 
Then the heart was accelerated, as was also the respiration, and the 
pupils became contracted. Sensibility and the power of motion were 
unaffected. 

In twelve minutes the gait of the animal became uncertain, the limbs 
were lifted higher than was natural, and the body swayed from side to 
side, and occasionally strong efforts had to be made to maintain the 
erect position. The pupils were still contracted, and sensibility ap- 
peared to be intact, 

This condition lasted twenty-two minutes, and then the pupils began 
to dilate. The posterior extremities were so far weakened as to render 
locomotion impossible, and the sensibility of the posterior parts of the 
body was materially impaired ; the respiration was very irregular, some- 
times being quite rapid, then ceasing for several seconds, and then be- 
coming slow. The pulse was still rapid, but weaker than at first. In 
a little less than an hour the animal was in a state of light coma, which 
lasted about twenty minutes. Recovery took place gradually, the phe- 
nomena of intoxication disappearing in an inverse order to their super- 
vention. 

Observation of the symptoms which ensue when alcohol in sufficient 
quantity is given to animals shows that the condition of intoxication 
may, as Marvaud * proposes, be divided into three periods or stages : 
1 "L'alcohol: son action physiologique," etc., Paris, 1372, p. 28. 



908 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

1. Period of Excitation. — Uncertainty in the movements, accelera- 
tion of pulse and of respiration, contraction of the pupils. 

2. Period of Perversion. — Muscular paralysis, beginning in the pos- 
terior extremities, irregularity of pulse and of respiration, dilatation of 
the pupils. 

3. Period of Collapse, — Complete paralysis of motion, anaesthesia, 
feebleness of the pulse and of respiration, stoppage of respiration and 
of the heart's action, death. 

Now, I was desirous of knowing how much of this condition was 
due to the presence of alcohol in the brain, and how much to disturb- 
ance in the quantity of blood normally present in this organ. In other 
words, I wished to ascertain whether alcohol increased or diminished 
the amount of blood circulating within the cranium. For this purpose 
I performed the following experiment : 

I trephined a dog, and secured a cephalohgemometer into the open- 
ing made by the trephine in the skull. I then administered an ounce 
of alcohol, diluted as in the previous experiment. In fifty seconds I 
detected alcohol in the expired air ; in four and a half minutes the res- 
piration was accelerated, the action of the heart became more rapid 
and strong, and the pupils were beginning to contract. Still there was 
no increase in the intracranial pressure, and I therefore knew that up 
to this time the amount of blood in the brain had not been increased. 
In six minutes and a half the dog's gait was staggering, and, though his 
movements were uncertain, there was no paralysis. The intracranial 
pressure was still unaltered. 

The fluid remained stationary in the tube of the instrument till sev- 
enteen minutes had elapsed. Then it began to rise slowly, and, with 
this increase in the intracranial pressure, paralysis of the posterior ex- 
tremities supervened. As the amount of blood contained in the crani- 
um became greater, the paralysis extended, the pupils dilated, and coma 
ensued. The return to sensibility and the power of motion was attend- 
ed with a diminution of the intracranial pressure, and was probably di- 
rectly dependent thereon. 

I repeated this very instructive experiment twice with similar re- 
sults. 

The deductions to be made from them are, that the first symptoms 
which result from the ingestion of alcohol are due to the presence of 
this substance in the brain, while the latter phenomena are, in part at 
least, the results of cerebral congestion. 

Note. — In these and other experiments detailed in this chapter, the presence of alco- 
hol in the expired air was determined by causing the breath to pass through a solution oi 
bichromate of potash in sulphuric acid, a test suggested by Masing, 1 and not by Lalle 
mand, Perrin, and Duroy, as generally supposed. 

1 "De mutationibus spiritus vini in corpus ingesti," 1854. 



ALCOHOLISM. 909 

In man a like sequence is observed. A single glass of wine induces 
an exhilaration and activity of mind before there is any evidence of an 
increase in the amount of blood circulating in the cerebral blood-vessels. 
In several subjects particularly sensitive to the action of alcohol, I have 
observed that the flushing of the face and increased vascularity of the 
fundus of the eye, as shown by the ophthalmoscope, were second in 
order of occurrence to others indicating mental excitement. 

But, as is well known, the immediate effects of a large quantity of 
alcohol, when taken into the human stomach, are not limited to mental 
excitement and flushing of the face. It does not come within the scope 
of this chapter to consider all of them ; but so far as the nervous sys- 
tem is concerned they properly come under notice. 

Levy * divides the phenomena of alcoholic intoxication, as they 
relate to the nervous system, into three stages : excitement, perturba- 
tion, and destruction of the functions of the brain and spinal cord. 
The stage of excitement is characterized by a sensation of heat in the 
skin of the whole body and by redness of the face. The eyes appear 
to be larger and more brilliant, the ideas flow more readily, the. ten- 
dency to talk is generally increased, but the articulation is usually not 
so distinct and exact as is natural. The disposition becomes more gen- 
erous, and perhaps more reckless as to consequences, although the 
bounds of propriety of conduct and truth of expression are not ex- 
ceeded. 

Occasionally a different set of symptoms results. The individual, 
from being naturally talkative, becomes taciturn and stolid, and a gen- 
erous disposition is changed to one of which churlishness and selfish- 
ness are the chief features. 

If the quantity of alcohol taken has been small, or if the individual 
now ceases to drink it, the subsequent stages do not supervene, and 
the equilibrium is soon restored witkout the occurrence of any abnor- 
mal condition. But, if the amount ingested has been large, or if the 
potations are continued, the second stage, that of perturbation, ensues. 

There are now vertigo, disturbances of sight — such as result from 
paralysis of one or more of the ocular muscles, and giving rise to double 
vision — contraction of the pupils, noises in the ears, and increased red- 
ness of the face. The sense of taste becomes weakened, the voice loses 
its natural inflections and becomes rough and monotonous, and the 
articulation is indistinct from partial paralysis and defective coordina- 
tion of the muscles of speech. 

The gait, from like causes, becomes weak and uncertain, and hence, 
if the individual attempts to walk, he staggers. The movements of the 
upper extremities are irregular, and often exhibit marked tremor like 
that which constitutes so prominent a feature of paralysis agitans, or of 
some of the forms of sclerosis affecting the brain and spinal cord. 
1 " Traite d'hygiene," tome ii., Paris, 1862. p. 63. 



910 TOXIC DISEASES CF THE NEKVOUS SYSTEM. 

Still greater alterations from the normal standard are shown in 
the mind than in other manifestations of nervous action. The most 
striking change occurs with the emotions, which generally assume an 
undue prominence and dominate over other of the mental faculties. 
And it not infrequently happens that the feeling which is most conspic- 
uous is the very opposite of that which is natural to the individual. 
Thus the brave man becomes cowardly, the timid courageous, the peace- 
able quarrelsome, the modest shameless, etc. Usually, however, the 
emotions, which the subject in his normal condition is able to control 
and to keep in proper subordination to the intellect and will, become 
exaggerated, and are no longer held in subjection. It- therefore hap- 
pens that, when this stage of alcoholic intoxication is reached, the indi- 
vidual, who while in his natural state is high-toned and spirited, is 
ready to take offense and engage in quarrels upon the slightest provo- 
cation, and often when no cause for his emotion and conduct exists. 
It is in this stage that outrages against the law are most apt to occur. 

The more purely intellectual part of the mind does not escape. The 
judgment is weakened, the memory impaired, the imagination exalted 
or perverted, and delusions, often having their origin in disordered 
sensations, and often arising in the mind without any accompanying 
illusion or hallucination, may assume the government of the thoughts 
and actions. The ability to grasp the details of a subject, and to com- 
prehend them, is greatly injured, or even altogether destroyed, and 
hence study or continuous and systematic thought is no longer pos- 
sible. 

In the third stage the full action of the alcohol is attained. The 
mental, sensorial, and motor functions are more or less completely abol- 
ished, and death, generally the direct result of suspension of the respir- 
atory movements, may ensue. When this degree of alcoholic intoxi- 
cation is at its height, the individual is dead to all external impressions. 
Boiling water may be poured on his body, but he does not feel it ; 
speech is impossible ; the sphincters are relaxed, allowing the contents 
of the bowels and bladder to escape ; the pupils are largely dilated ; 
the breathing is slow, heavy, and often stertorous ; the face is swollen 
and purple from the circulation of non-oxygenized blood through the 
vessels ; and the power of thought is extinct. With the exception of 
that part of the cerebro-spinal axis which presides over the functions 
of respiration and circulation, the individual is to all appearance dead. 
It not infrequently happens that this region is so fully affected that 
life is abolished. 

Such are the immediate effects of large quantities of alcohol when 
ingested into the human stomach. No one can fail to observe that 
most of the remarkable phenomena which follow on the administration 
of this liquid are connected directly or indirectly with the nervous sys- 
tem. Indeed, experiments performed upon animals, with reference to 



ALCOHOLISM. 91 1 

this point, as well as careful observation of the effects of alcohol on the 
human oro-anism, show that this substance has a signal affinity for the 
nervous tissue, and that it is even capable of acting powerfully on the 
brain, the spinal cord, and the sympathetic system, without the inter- 
mediation of the blood. Instances are on record, and I have myself 
witnessed one such, in which a large quantity of alcoholic liquor taken 
into the stomach has produced death in a few minutes ; and Orfila ' cites 
a case in which a man died immediately from the effects of an excessive 
dose of brandy. I have several times killed rabbits in less than a min- 
ute by introducing an ounce of pure alcohol into the stomach. In such 
cases the action is not exerted through the medium of the blood, but 
directly on the sympathetic system or medulla oblongata by the ter- 
minal nerve-branches in the stomach. Indeed, if, as I have frequently 
done, a like amount of alcohol be injected into the blood directly, death 
does not ensue with so great a degree of rapidity. 

Marcet a says : 

" By experimenting on frogs I have shown, in a paper read to the 
British Association, in 1859, that a sudden temporary suspension of 
sensibility or shock is occasionally brought on when the hind-legs of 
these animals are suddenly immersed in strong alcohol ; and I have ob- 
tained positive proof that this phenomenon is due to an influence ex- 
erted exclusively on the extremities of the nerves supplying those limbs, 
by observing this same effect to take place after the circulation of the 
parts in contact with alcohol had been entirely arrested. When, on 
the contrary, the nerves of the limb immersed in alcohol were severed 
from their centre, the circulation being left undisturbed, a shock never 
happened. In the experiments in question it was obvious that the sud- 
den occurrence of insensibility or anaesthesia was due to an action of 
the alcoholic fluid on the extremities of the cerebro-spinal nerves, which 
action had been transmitted by these nerves to the brain ; the phenom- 
ena of reflex action continued, for the respiration appeared unimpaired, 
and after the lapse of some minutes the shock passed off with a return 
of sensibility, although the frog's hind-legs had not been removed from 
the alcohol." 

I have repeated Marcet's experiments, with every possible precau- 
tion to guard against fallacy, and am satisfied that his conclusions are 
correct. In one experiment I divided all the tissues of both posterior 
limbs of a large frog, except the sciatic nerves. I then placed small 
slips of thin glass under these nerves, and moistened them with a few 
drops of pure olive-oil, so as to prevent the alcohol acting by imbibi- 
tion. I then plunged both limbs up to the thighs in absolute alcohol. 
Shock ensued in eleven seconds, and lasted about five minutes. Dur- 
ing its continuance the animal was insensible and anaesthetic. 

1 " Toxicologic," tome ii., p. 528. 

2 "Chronic Alcoholic Intoxication, 1 ' Xew York, 1868, p. 10. 



912 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

In another instance I performed the converse experiment of exsect- 
mg the sciatic nerves, leaving the other tissues of the extremities in- 
tact. I then, as before, inserted both legs into absolute alcohol. No 
shock ensued, and the animal was not apparently affected by the alco- 
hol till twenty-two minutes had elapsed. 

Absorption of alcohol from the stomach is sometimes greatly de- 
layed, and yet many of the effects of the substance are observed. Most 
of us have seen an intoxicated man relieved immediately by the full 
action of an emetic. Of course the emetic in such a case can only 
remove the non-absorbed alcohol still remaining in the stomach, and 
yet the symptoms of inebriation disappear on its ejection. It can only 
have acted through the nervous system, without the intermediation of 
the blood. 

Observations and experiments such as these are very striking and 
important. They tend to show that the action of alcohol is exerted 
upon the nervous system in a twofold manner, and they are evidence 
of the remarkable affinity which the substance in question has for the 
nerve-tissue. 

Post-mortem examinations of persons who have died directly from 
the effects of alcohol, or who were during life habitual drunkards, also 
show how powerfully the nerve-centres are influenced by this agent. 
In extreme cases it has not infrequently happened that the brain, on 
being exposed, has evolved a strong odor of alcohol. It is true thai 
the experiments of Dr. Hutson Ford 1 appear to show that alcohol is a 
normal constituent of the blood ; but it is very certain that the quan- 
tity is altogether too small to give the characteristic odor of this sub- 
stance, although the reaction with chromic acid, and the distillate being 
capable of ignition and burning like alcohol, are affirmative evidences 
of great significance. He did not, however, examine the brain for alco- 
hol, and my own experiments on this point, with the brains of dogs and 
oxen, and of men not addicted to the use of alcoholic liquors, have 
given negative results. Aware, however, of the great affinity which 
the cerebral and other nerve-tissues have for alcohol, it seems to me 
that if this substance is normally present in the blood it ought to be 
found as well in the brain as in the lungs and liver, unless, as may have 
been the case, the alcohol discovered by Dr. Ford in these organs and 
in the blood was a post-mortem production. 

With the view of still further elucidating this subject, I fed a rabbit 
largely every day with bread soaked in whiskey. In the course of that 
time the animal received nearly a pint of the liquor, but beyond being 
somewhat stupefied it did not appear to be seriously inconvenienced. 
At the end of ten days the animal was killed. 

I then removed the brain, the spinal cord, and all the large nerves, 

1 "Normal Presence of Alcohol in the Blood," Journal of the Elliott Society oj 
Natural History, vol. i., Charleston, 1859. 



ALCOHOLISM. 913 

and treated them separately with distilled water after cutting them 
into small pieces. They were then thrown upon a filter and strongly 
pressed. 

The three separate portions of liquid extract were then distilled 
several times, and finally treated with quicklime and again distilled. 
The odor of the distillates was almost sufficient of itself to establish 
the presence of alcohol, but, when the vapor from each was passed 
through the solution of bichromate of potash in sulphuric acid the 
characteristic green color resulting from the action of alcohol was at 
once produced. 

So far as I am aware, no previous experiments had established the 
existence of alcohol in the spinal cord and the nerves. 

A portion of the blood of the same animal treated in like manner 
failed to exhibit evidence of the presence of alcohol. The experiments, 
therefore, showed that the nervous tissue had a greater affinity for this 
substance than the blood. 1 

Besides the moibid conditions which exist in the nervous system as 
the direct result of the ingestion of alcohol in large quantities, this sub- 
stance is capable of causing other patho-anatomical states which have 
already been described in this treatise. 

Treatment. — In the first place, in the treatment of chronic alcohol- 
ism, the physician should insist upon entire cessation from the use of 
alcoholic liquors. It usually happens that the bowels are deranged by 
constipation or diarrhoea. In either case a mild purgative will be found 
of service. I know of nothing better than the following : I£ . Aloes, 
ext. fel. bovis exsic, aa grs. xv ; resinae podophilli, grs. ij. M. ft. in 
pill no. v. Dose, one every alternate day. 

For the special treatment of the condition the oxide of zinc in doses 
of two or three grains three times a day has been strongly recom- 
mended by Marcet, and is certainly possessed of great power in this 
direction. Under its use the symptoms soon begin to disappear, and 
the patient to resume his normal condition of mind and body. But in 
my experience it is far inferior to the bromides of potassium, sodium, 
calcium, or ammonium, which, when given in doses of from fifteen to 
thirty grains in solution three times a day, are exceedingly efficacious. 
Even they, however, are inferior to the bromide of zinc, which may be 
administered in the dose of two grains in solution in water or simple 
syrup three or four times a day — gradually increased, as rapidly as the 
stomach will permit, to two or three times that quantity. 

In some cases, especially in those in which insomnia is a prominent 
feature, the zinc compound may be advantageously given with either 
of the other bromides mentioned. 

1 These experiments were performed before the New York Neurological Society, May 
4, 1874, and are detailed at length in the Psychological and Medico-Legal Journal for 
July, 1874. 

59 



914 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

I am very sure that in digitalis we have an important adjunct to the 
treatment mentioned. It not only acts as a tonic to the heart, but it 
is the most active agent we possess as an eliminant of alcohol through 
the kidneys. I prefer the infusion in doses of a tablespoonful three 
or four times a day. The tincture may be given in doses of from fif- 
teen to thirty drops, as often. 

In acute alcoholism, or delirium tremens, the treatment depends 
very much upon the mode of origin of the disease. 

In those cases which have resulted from the sudden cessation from 
the use of alcoholic liquors, opium with brandy or whiskey should be 
given. The main indication is to procure sleep as soon as possible, and 
I am aware of no means so effectual in cases of this kind as the 
hypodermic injection of large doses of morphia — one-fourth to half a 
grain — as often as may be required, combined with the internal admin- 
istration of brandy or whiskey in moderate quantities. 

When, however, the affection has come on during a debauch, noth- 
ing can be much worse than either of those substances. They add fuel 
to the flame. In such cases the bromides, in large doses, combined with 
digitalis, are the most effective remedies. A drachm of the bromide of 
potassium, for instance, may be given in solution in a tablespoonful of 
infusion of digitalis every hour or two, and it will generally happen 
that sleep will follow, with the cessation or mitigation of all the perma- 
nent symptoms. 

The hydrate of chloral has been recommended in delirium tremens, 
but I have no personal experience of its use. 

The monobromide of camphor has been used successfully in delir- 
ium by M. Seneffe, of Belgium, and by Dr. O'Hara, of this country. I 
have also recently employed it in one case — administering four grains 
in capsule every hour. After the eighth dose the patient slept four 
hours. The remedy was again given as before, and after six doses 
another period of sleep, this time of six hours' duration, was obtained. 
The further administration was not necessary. 

With the medical treatment in either form of delirium tremens the 
strength should be supported with beef-tea, and, after convalescence, 
quinine, iron, and strychnia, will prove of service. 



BROMISM. 915 

CHAPTER III. 

BROMISM. 

In view of the facts that the bromides of potassium, sodium, calcium, 
lithium, and ammonium, are necessarily administered in several diseases 
of the nervous system, notably in epilepsy, in large doses and for long 
periods, and that a peculiar condition is thereby induced, it is impor- 
tant that the resultant phenomena should be recognized. 

In adults it is rarely the case that any decided symptoms of bromism 
are caused by doses of less than thirty grains daily, and not often that 
forty-five grains a day produce them in any great intensity. In chil- 
dren, however, and sometimes in weak individuals, smaller quantities 
will give rise to very well-marked phenomena. 

Symptoms. — The first symptom to make its appearance in cases of 
bromism is drowsiness. The patient sleeps not only at night, but in 
the day, and often under circumstances in which sleep would appear to 
be almost out of the question. Feebleness of the arms and legs, espe- 
cially of the latter, is generally the next sign. The gait becomes titu- 
bating, and falls are apt to occur, especially in children. The grasp 
of the hands is weak, and there appears to be an anaesthesia of what 
may be called the muscular sense, for articles held are dropped unless 
the sight be kept upon them. 

Articulation is very early interfered with, so that the speech becomes 
thick and indistinct. Words are omitted and others are clipped of their 
final syllables, or are slurred over in a tangled mass of incomprehensible 
utterances. 

The action of the heart is weakened, and at the same time rendered 
more frequent ; the skin is cold and clammy, the countenance is pale, 
and the pupils, from being at first somewhat contracted, become widely 
dilated and somewhat insensible to light. 

The tongue is reddened, thickly coated, dry, and sometimes sore. 
The breath has the odor of bromine or is otherwise offensive ; the bow- 
els are usually constipated, and the urine is ordinarily increased in quan- 
tity. 

The skin, even in cases in which the other symptoms of bromism 
are not very evident, is the seat of numerous pustules, especially that 
covering the face, neck, back, and chest, and occasionally large boils or 
carbuncles make their appearance. 

The fauces are often intensely congested, and aphthous patches ap 
pear on the mucous membrane of the buccal cavity. The respiration 
becomes hurried, cough is often induced, and bronchitis or congestion 
of the lungs may ensue. 

The sensibility of the pharynx is markedly impaired, and its reflex 
excitability is almost if not entirely abolished. It requires a mental 



916 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

effort for the patient to swallow, and manual irritation of the fauces 
fails to excite nausea or efforts to vomit. 

Finally, locomotion becomes impossible, the patient is in a state of 
continual stupor, incapable of making known his wants — in fact, hav- 
ing no wants — and unable to recognize those about him ; the urine and 
faeces are passed involuntarily, the lungs are engorged, the heart be- 
comes still weaker, and if the administration of the bromide be not sus- 
pended death ensues. 

In a paper which I published 1 several years ago, I called attention 
to this remarkable condition, and adduced several cases in illustration 
of the points then brought forward. They were noticed by Huette 2 
many j'ears ago, though not very perfectly. He was the first to ob- 
serve the effects of bromide of potassium upon the generative function 
in the abolition it causes of sexual desire and power. 

Before the extreme influence of the bromides is attained, a patient 
under their influence presents phenomena very similar to those exhibit- 
ed by a drunken person. A case which formed one of the series given 
in the paper referred to is so apposite in the present connection that 1 
cite it here : 

A gentleman consulted me in January, 1867, for severe headache, 
with which he had suffered for many years. He informed me that he 
had once fallen from the rigging of a vessel, had struck his head, and 
was rendered insensible for several hours. Subsequently he had a sun- 
stroke in Texas. I considered this a suitable case for the administra- 
tion of the bromide of potassium, and accordingly prescribed for him a 
teaspoonf ul three times a day of a solution containing one ounce of the 
medicine to four ounces of water. He thus took about fifteen grains 
at a dose. The effects of this were so pleasant to him, and yet not alto- 
gether so strong as he desired, that he began to increase the dose. Be- 
ing absent from the city for two or three weeks at that time, I did not 
witness the phenomena. I was informed, however, that he had exhib- 
ited symptoms of mental aberration. These wore off on the cessation 
of the medicine, and when I returned he was comparatively well. 

His headaches, however, soon came back with all their original vio- 
lence, and at his earnest solicitation, and under his promise not to ex- 
ceed the prescribed dose, I again gave him the bromide. He very soon 
began to increase the quantity, and finally seemed to have lost all con- 
trol of his appetite for it. At this time I ascertained that he was in the 
habit of having his four-ounce vial containing an ounce of the bromide 
filled every day. The first obvious effect was an unsteadiness of gait. 
So great was this that he was frequently taken for a drunken man, and 
on one occasion was arrested by the police, confined in a cell all night, 

1 *' On some of the Effects of the Bromide of Potassium when administered in Large 
Doses," Quarterly Journal of Psychological Medicine, vol. iii., 1869, p. 46- 

2 Gazette Medicate \ June, 1850. 



BROMISM. 917 

and fined the next morning, notwithstanding my statement of the facts 
to the police superintendent. On another occasion I met him in the 
street, as I was going to visit him. He was now decidedly insane ; 
had delusions that lewd women had got into his mother's house ; that 
he was pursued by the police ; that his life was threatened by members 
of the family ; that he had thousands of dollars of gold sewed up in his 
clothing, etc. When I met him his appearance and manner were very 
similar to those of a drunken man, except that his face was exceedingly 
pale. This gentleman was a total-abstinence man as regarded intoxi- 
cating liquors of all kinds. His manner was excited and rambling, and 
his hands were constantly busy either in fumbling in his pockets, tying 
his shoes, picking threads from his clothing, or in reaching for the gold 
which he believed was concealed in the lining of his coat. His charac- 
ter had also undergone a radical change. From having been very frank 
and brave, he had become excessively timid and suspicious of every 
trifling circumstance. 

Up to this period I was not quite sure that he was suffering from 
the effects of bromide of potassium. His symptoms were in many re- 
spects so much like those of an ordinary attack of acute mania, and his 
antecedents were of such a character as to predispose him to an acces- 
sion of the kind, that I had reasons for my doubts. Nevertheless, I en- 
deavored to stop his use of the bromide. This was a difficult task, for, 
notwithstanding all efforts, he continued to get hold of it. At last it 
was ascertained that he had secreted large quantities of it in various 
out-of-the-way places about the house. 

His mental derangement had now become so prominent and con- 
stant that his friends became alarmed for his own and their safety. He 
had several times attempted to throw himself from the window, and had 
battered down a door with an axe in order to escape from some imagi- 
nary danger. Under these circumstances I recommended his committal 
to a lunatic asylum, and he was accordingly removed to Sanford Hall, 
at Flushing. Here his symptoms gradually disappeared, and in a month 
he returned to his home well. He has continued so to this day, with 
the exception that his headaches, which had disappeared while he was 
under the influence of the bromide, became as severe as at first, and 
still continue. 

This was certainly an extreme case, but others fully as well marked 
have come under my notice. 

The effects due to the continued administration of the bromide of 
potassium have not been more clearly, fully, and at the same time 
succinctly stated than by Dr. E. H. Clarke. 1 He says: 

"The principal phenomena following the continued dose are: acne; 

1 "The Physiological and Therapeutical Action of the Bromide of Potassium and Bro- 
mide of Ammonium," by Edward H, Clarke, M. D., and Robert Amory, M. D., Boston, 
872, p. 30. 

60 



918 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

salivation and salt taste in the mouth ; irritation of the fauces, generally 
with oedema and redness, and sometimes with paleness of those parts; 
moderate anaesthesia of the pharynx; laryngo-bronchial weakness, some- 
times with cough and sometimes with a changed or whispered voice, 
rarely with aphonia; a fetid or bromized breath; occasional stammer- 
ing; increase of renal secretion; diminution of mucous secretion gen- 
erally; slight constipation, and, in a few rare cases, diarrhoea; sense 
of mental and physical languor or weakness; sometimes temporary 
impairment of the memory, general aspect of hebetude or indifference; 
more or less somnolence ; repression, and occasionally temporary aboli- 
tion of sexual desire and power; impaired locomotion, which, when the 
dose is excessive, resembles the gait of locomotor ataxia; diminished 
nervous sensibility in general, and especially diminution of reflex sensi- 
bility; and, finally, an increase of destructive without a corresponding 
increase of constructive metamorphosis, and consequent emaciation." 

When administered in larger quantities than are just sufficient to 
produce the foregoing symptoms, the phenomena, as detailed by Dr. 
Clarke, are: 

"The fetid breath becomes nauseous; oedema supervenes on conges- 
tion of the uvula and fauces; the whispering voice sinks into aphonia; 
sexual weakness degenerates into impotence; muscular weakness be- 
comes complete paralysis; reflex, general, and special sensations dis- 
appear; the ears do not hear, or the eyes see, or the tongue taste; the 
expression of hebetude becomes first that of imbecility, and then that of 
idiocy; hallucinations of sight and sound, with or without mania, pre- 
cede general cerebral indifference, apathy, and paralysis; the respira- 
tion, without the stertor of opium or alcohol, is easy but slow; the tem- 
perature of the body is lowered; as the bromism becomes more pro- 
found, the patient lies quietly in his bed, unable to move, or to feel, or 
swallow or speak, with dilated and uncontractile pupils, and scarcely 
any change of the color of the skin or face; the extremities grow 
gradually colder and colder; the action of the heart becomes feeble 
and slower, till it ceases altogether." 

Dr. Clarke reports one death, in which this result was probably due 
to bromism. Three have come under my observation, in which bromism 
was probably instrumental in hastening a fatal termination. In one of 
these the patient, a young lady, was the subject of epilepsy. She 
resided out of the city, and I prescribed the bromide of potassium in 
doses of fifteen grains three times a day. While taking it, and fully 
under its influence, she contracted pneumonia ; but, without my knowl- 
edge, the medicine was continued, and she died. 

The second case was that of a lady forty years of age, also subject 
to epilepsy, for whom I prescribed the bromide of sodium in doses of 
fifteen grains three times a day. The bromic cachexia soon became 
strongly marked, but, as I saw her every day, I did not think it advis- 



BROMISM. 919 

able to reduce the doses. She went out every day, and on one occa- 
sion crossed the North River ferry to meet some friends. She caught 
a severe cold, pneumonia supervened, and, though the administration 
of the medicine was at once stopped, she died in the second stage of 
the disease. 

In both these cases the bromide probably was indirectly the cause 
of death by the asthenia which it produced. 

In the third case the patient, a lady from the South, also an epi- 
leptic, visited New York to consult me relative to her disease. I pre- 
scribed for her as in the last-named case, and, after remaining a fort- 
night in the city, she returned home with no great degree of bromism. 
But, after her departure, the toxic influence became more strongly 
marked, and, before I could be written to and my answer obtained, the 
medicine being continued all the time, death occurred. In this instance 
the result was doubtless entirely due to bromism. 

Causes. — For the production of bromism, more or less prolonged 
administration of a bromide — the continued dose of Dr. Clarke — is 
necessary. In my experience the potassium and sodium salts equally 
cause it; the lithium, calcium, and ammonium compounds, less readily; 
the bromide of zinc not at all; but this result may be due to the fact 
that this preparation is not administered in as large doses as the others. 
Great differences exist among individuals in regard to the capacity to 
be brought under the full influence of a bromide; but I know of no 
signs by which these differences can be previously ascertained, except 
those of age and sex ; children and women being more readily affected 
as a rule. 

The administration of a bromide in a largely diluted form facilitates 
the action of the drug on the system, and consequently leads more 
readily to the promotion of bromism. This is probably due to the fact 
of its greater endosmotic power, and consequent more rapid absorption 
into the blood. 

The Diagnosis of bromism scarcely calls for remark. The Prognosis 
is almost invariably favorable if the administration of the drug be 
stopped when the phenomena become profound and there are no serious 
superadded affections present. 

Of the Morbid Anatomy nothing is known, and the Pathology is, 
therefore, based entirely on what has been ascertained relative to the 
physiological and therapeutic action of the bromic compounds. Chief 
among these are the facts that it diminishes the amount of blood circu- 
lating in the cerebral blood-vessels, and that it lessens the irritability 
of the whole cerebro-spinal and sympathetic nervous systems. These 
effects were set forth in a paper x published more than ten years ago. 
and have been generally confirmed by subsequent observers, and by my- 

1 "On Sleep and Insomnia," New York Medical Journal, 1?65. 



920 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

self in various memoirs. 1 Relative to the influence which the bromides 
exert in diminishing the quantity of blood in the brain, the fact admits 
of actual demonstration by means of inspection through the trephined 
skulls of animals and by the use of the. cephalohsemometer described 
in the introduction to this work. 

Many of the most striking phenomena of bromism are the result of 
the cerebral anaemia which the bromides produce. The paleness of the 
countenance, the dilatation of the pupils, the mental and physical weak- 
ness, the somnolence, the cardiac debility, all result from the intra- 
cranial condition. 

Among the secondary effects are those cited by Bartholow : 2 the 
retardation of the process of destructive metamorphosis, the diminution 
of the sexual desire and power, and gastric derangement. 

M. Laborcle 3 has performed a number of experiments on man and 
other animals with the bromide of potassium. Four or five minutes 
after the administration of from three to six grains to frogs, a slight 
general excitement, with moderate tetanic movements, was produced. 
Weakness followed, and then there was a condition of flaccidity, during 
which reflex action was entirely abolished. The heart was but slightly 
affected, and continued to contract for several hours after this loss of 
reflex power. Laborde concludes, therefore, that bromide of potassium 
has no special action on the heart, muscles, encephalon, or nerves, but 
that it mainly and primarily injures the spinal cord. 

These views are doubtless true as regards the frog, in which animal 
the spinal cord is mainly the seat of the mind, and therefore any cere- 
bral influence must be very slightly manifested ; but they certainly are 
not correct so far as man and the superior animals are concerned. 

Other observers have written relative to the physiological effects of 
the bromides, among whom MM. Damourette and Pelvet 4 may be men- 
tioned. 

In the work of Drs. Clarke and Amory, to which reference has al- 
ready been made, Dr. Amory enunciates, among other propositions, the 
following : 

" The loss of reflex action is due to the diminution of blood in the 
periphery of the nerves and also of the central nervous system, this last 
occurring after the first. 

" The action of bromide of potassium on the nervous system may be 
explained by its action on the capillary, arterial, or central circulation." 

These propositions are supported by various experiments, and ap- 
pear to be well established. 

1 " On some of the Effects of the Bromide of Potassium," etc., Quarterly Journal cj 
Psychological Medicine, January, 1869. 

2 Cincinnati Lancet and Observer, 1865. 

3 Comptes Rendus, July 8, 1868. 

4 Bulletin generate de Iherapeutique, 1867, pp. 241, 289. 



HYDRARGYSM. 921 

The recent work of Voisin ' adds nothing to our previous knowledge 
of the subject. 

Treatment. — There is no special treatment for bromism beyond that 
which consists in suspending at once the administration of the medi- 
cine, facilitating its elimination from the system, and sustaining the 
strength. Dr. Clarke 2 has shown that the fasces do not contain an ap- 
preciable quantity of the bromide of potassium, even when it is being 
taken in large quantity. He found that it is mainly eliminated by the 
kidneys and by the skin. It is difficult to avoid the opinion, in view of 
the odor of the breath of persons taking a bromide, that bromine is 
eliminated with the expired air, but Dr. Clarke's experiments appear to 
establish the negative. The judication, therefore, is to administer diu- 
retics and diaphoretics. Nothing is better for the first than digitalis, 
which not only acts upon the kidneys, but is also a tonic to the heart, 
and for the latter than warm drinks, such as infusion of flaxseed, lemon- 
ade, etc., which are also more or less diuretic. 

The strength of the patient should be sustained with brandy or wine, 
quinine, beef-tea, etc. 



CHAPTER IV. 

HYDRARGYSM. 

Symptoms. — The consequences to the nervous system, from the slow 
absorption of mercury into the organism, have been known for many 
years. The principal phenomenon witnessed is tremor, but there are 
other symptoms which serve for the recognition of the nature of the 
disorder. 

Thus the gums are swollen and tender, the breath fetid, the teeth 
become loose, especially those of the lower jaw, and there is a metallic 
taste in the mouth. The lining membrane of the mouth and throat be- 
comes inflamed, and ulcerations very generally occur in the fauces. The 
quantity of saliva is greatly increased. 

These symptoms exist mainly in the first stage of hydrargysm, and 
constitute what is generally called salivation. But, if the mercury con- 
tinues to be taken into the system, another series of phenomena ap- 
pears. Or, if the absorption has been extremely slow, the foregoing 
may be in great part, or entirely, absent. 

The symptoms referred to are paleness or lividity of the counte- 
nance, the frequent occurrence of nasal haemorrhages, and marked 
mental weakness. The physical strength gradually becomes less, and 
tremor makes its appearance, mostly confined, in the early stages at 

1 "De l'emploi de bromure de potassium dans les maladies nerveuses," Paris, 1875 

2 Op. cih, p. 139. 



922 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

least, to the superior extremities and the head. Finally, the lower 
limbs are affected, and, in addition, are generally the seat of oedema. 
Pains in the bones, and caries, and necrosis, especially of the maxillary 
bones, may occur together with ulcerations of the soft parts. 

The mental symptoms are generally strongly marked. There are 
hallucinations and delusions, accompanied sometimes with a high de- 
gree of maniacal excitement. Epileptiform convulsions may occur, as 
may also paralysis of various parts of the body, and finally, unless re- 
lief be afforded, death ensues. 

Causes. — Mercury may be taken into the system and be the cause of 
slow poisoning, through the skin, the stomach and intestines, and the 
lungs. Fire-gilders, looking-glass manufacturers, barometer-makers, 
the workers in quicksilver-mines, bronzers, the makers of artificial flow- 
ers, and photographers, exposed as they are to the vapor, the fine pow- 
der, or a solution containing mercury, are therefore liable to its toxic 
influence. Hydrargysm has also been known to be induced by the long- 
continued administration of preparations of mercury in medical prac-. 
tice, and even from the filling of a tooth with an amalgam. 

I have known of a case of mercurial tremor, produced in a young 
lady by the use of a solution of corrosive sublimate as a cosmetic to 
remove pimples from the face. 

The Diagnosis of hydrargysm is in general mucb' elucidated by the 
clinical history of the case and the knowledge that the patient has been 
exposed to mercurial emanations. In addition, the tremor, the fetid 
breath, loosening of the teeth, caries of the bones, and the muscular 
weakness, are diagnostic signs of value, while the absence of the blue 
line on the gums — although it is stated that such a line is sometimes 
present — and the fact that the extensors are not especially the seat of 
paralysis will suffice for the discrimination of hydrargysm from plumb- 
ism. 

But the diagnosis is rendered quite certain by the administration of 
the iodide of potassium, which, as Melsens has shown, separates mer- 
cury from its combinations with the tissues of the body, forming with it 
a new compound — the iodide of mercury — which is eliminated with the 
urine. All that is necessary, therefore, is to give the iodide of potassi- 
um in large doses to a patient suspected to be suffering from hydrar- 
gysm, to put a few drops of the urine, excreted during the second day, 
on a bright copper plate, and then add a drop of hydrochloric acid. 
A blight metallic stain will be found on the plate if mercury be present. 
The iodide of mercury is decomposed and the metal is precipitated as 
stated. 

The Prognosis is generally favorable if the patient can be removed 
from further contamination with mercury and be subjected to proper 
treatment. 

Morbid Anatomy and Pathology. — There are no data by which we 



ARSENICISM. 923 

can form an opinion relative to the anatomical changes induced in the 
nerve-tissues by the action of mercury. It is probable, as M. See as- 
serts, that this substance, like lead, forms an albuminate of mercury 
both in the blood and the solid parts of the body. Beyond this fact 
we have nothing except the gross alterations found in the stomach, the 
kidneys, and other organs, when mercury has been taken into the sys- 
tem in large enough quantities to cause death. It is perhaps scarcely 
necessary to say that the accounts which have been given of metallic 
mercury being found in globules in the brain and other organs are not 
correct. 

A curious circumstance, which has sometimes been observed, is the 
occurrence of salivation in the cases of persons who have taken mercu- 
ry, but who have not exhibited any indications of hydrargysm previous 
to the administration of iodide of potassium. It appears that the mer- 
cury set free from its albuminate compounds is enabled, while travers- 
ing the system in its exit through the kidneys, to exert a toxic power. 

I have never witnessed cases of the kind, and they must be rare. It 
will be recollected that a like action is claimed for lead. 

Treatment. — The special means of treatment consists in the. free ad- 
ministration of the iodide of potassium in accordance with the discovery 
of M. Melsens, already alluded to. Under the action of this remedy 
the symptoms of hydrargysm speedily disappear, and the patient re- 
gains his normal or almost his normal condition. The worst case of 
the affection that has come within my experience, was that of a look- 
ing-glass maker of this city, in whom the tremor and other evidences 
of cachexia were exceedingly striking. He was unable to write, from 
paralysis, and barely able to shuffle about his room. I gave him at 
once thirty grains of the iodide a day, in divided doses, and in the 
course of a week doubled the quantity. He immediately began to 
mend, and was well in less than five weeks. 

Of course, while under treatment the patient must not be subjected 
to continual poisoning from mercury. 

Tonics — -iron, quinine, and strychnia — are useful adjuncts. 



CHAPTER V. 

ABSEN-IOISM. 



The Symptoms indicative of slow poisoning by arsenic are generally 
quite characteristic. There are vomiting, a sensation of heat in the 
throat and stomach, colicky pains, weakness of the limbs, tremor, ver- 
tigo, haemorrhage from the nostrils, puffiness of the face, especially 
about the eyes, attacks of syncope or of epileptiform convulsions, pains 



924 TOXIC DISEASES OF THE NERVOUS SYSTEM. 

in the joints and contractions of the fingers and toes, numbness some- 
times amounting to complete anaesthesia, and paraplegia. 

In addition there are sometimes ophthalmia and various papular and 
vesicular eruptions on the skin. 

Death is the almost inevitable consequence if the exposure to 
toxication continues, or speedy relief be not afforded by medical treat- 
ment. 

The Causes of arsenical cachexia are, like those of lead and mercury, 
to be found generally with those whose occupation requires exposure 
to contact, through the lungs, skin, or alimentary canal, with arsenical 
preparations. It is thus met with in furriers, who use arsenious acid as 
a preservative; in taxidermists, who employ it for a like purpose; in 
naturalists, who sprinkle it over their zoological specimens, and who in 
handling them absorb the powder through the lungs ; in the manufact- 
urers of paper-hangings ; in dressmakers, who are obliged to handle 
green tarlatan ; in makers of artificial flowers, and in the workers in 
chemical manufactories, where arsenical preparations are made; and in 
those who labor in arsenic-mines. 

It has also occurred in persons occupying rooms hung with the brill- 
iant green-velvet paper into the manufacture of which arsenic enters 
in large quantities. 

Notwithstanding the general susceptibility of mankind to the dele- 
terious influence of arsenic, it appears that the system may become so 
habituated to its use as actually to thrive under it. This is the case 
with the arsenic-eaters of Styria, who take habitually from two to four 
or five grains daily, and who, nevertheless, are extremely healthy, and 
even rugged-looking people. 

The Diagnosis is not a matter of difficulty, especially if the clinical 
history be inquired into, and the Prognosis, except in extreme cases, is 
not unfavorable after the patient is removed from further contact with 
arsenic. 

The Morbid Anatomy and Pathology, so far as the nervous system 
is concerned, are not known, and except in acute cases of arsenical 
poisoning, with which, however, we are not now concerned, there are no 
definite lesions discoverable in other parts of the body. 

The Treatment consists in removing the patient from further expos- 
ure, and subjecting him to the most favorable hygienic influences, the 
strength being maintained by tonics. If there are contractions of an\ 
of the limbs, passive motion, frictions, and electricity, are indicated. 



INDEX. 



PAGE 

Abdominal sympathetic, pathology of. . . 865 

Abscess, chronic cerebral 265 

Acromegaly 878 

symptoms 878 

prognosis 879 

morbid anatomy and pathology 879 

treatment 880 

Active cerebral congestion 32 

varieties of 32 

symptoms 33 

causes 55 

diagnosis 58 

prognosis 60 

morbid anatomy 61 

pathology 62 

treatment 64 

Acute alcoholismi 901 

symptoms 901 

Acute ascending paralysis 868 

symptoms . . . ; 868 

causes 869 

diagnosis 869 

prognosis 869 

morbid anatomy and pathology 869 

treatment 870 

Acute cerebral meningitis 212 

symptoms 212 

causes 216 

diagnosis 217 

prognosis 217 

morbid anatomy 218 

pathology 218 

treatment 219 

Acute general myelitis 429 

symptoms 429 

Acute myelitis 429 

Acute neuritis 806 

symptoms 806 

causes 807 



PAGE 

Acute neuritis, diagnosis 807 

prognosis 807 

morbid anatomy and pathology 807 

treatment 808 

Acute partial myelitis 431 

symptoms 431 

causes 433 

diagnosis 434 

prognosis 435 

morbid anatomy and pathology 435 

treatment 436 

Acute spinal meningitis 41 3 

Acute spinal meningitis, symptoms 413 

Affections, hysteroid 742 

Agraphia 202 

Alcoholism 896 

symptoms 897 

causes 902 

diagnosis 904 

prognosis 904 

morbid anatomy and pathology 904 

treatment 913 

Alcoholism, acute 901 

Alcoholism, chronic 896 

Alternating paralysis 115 

Amyotrophic lateral spinal sclerosis 556 

symptoms 556 

causes 560 

diagnosis 560 

prognosis 561 

morbid anatomy and pathology 561 

treatment 567 

Amnesia 202 

Ansemia, cerebral 70 

Anaemia, partial cerebral 132 

Ansemia, spinal 374 

Ausemia of antero-lateral columns of cord 397 

symptoms 398 

diagnosis 399 



926 



INDEX. 



PAGE 

Anaemia of antero-lateral columns of 

cord, prognosis 399 

morbid anatomy and pathology 400 

treatment 404 

Anaesthesia, lead 890 

Anaesthesia, neural 834 

Ansesthesia of cutaneous nerves 834 

symptoms 834 

causes 836 

diagnosis 836 

prognosis 836 

morbid anatomy and pathology 837 

treatment 837 

Ansesthesia of fifth pair 837 

symptoms 837 

causes 838 

Anaesthesia of fifth pair, diagnosis 838 

prognosis 838 

morbid anatomy and pathology 838 

treatment 838 

Anapeiratic paralysis 784 

symptoms 785 

causes 787 

diagnosis 788 

prognosis 788 

morbid anatomy and pathology 788 

treatment 788 

Ankle clonus 550 

Anterior and posterior tracts of gray mat- 
ter, inflammation of. 534 

Anterior columns, inflammation of. 548 

Anterior polio-myelitis 438 

Anterior tract of gray matter, inflamma- 
tion of 437 

Antero-lateral columns of the cord, anae- 
mia of 397 

Aphasia 182 

Apraxia 202 

Arsenicism 923 

symptoms 923 

causes 924 

diagnosis 924 

prognosis 924 

morbid anatomy and pathology 924 

treatment 924 

Athetosis 315 

morbid anatomy and pathology 321 

treatment 325 

Atrophy, neural 317 

Atrophy of the cerebellum 354 

Basilar meningitis, chronic 231 

Brain, syphilis of 325 

Brain, tumors of. 296 

Bromism 91 5 

symptoms 915 

causes 919 

diagnosis 919 



PAGE 

Bromism, prognosis 919 

morbid anatomy 919 

treatment 921 

Capsule, internal ; . 339 

Catalepsy 742 

symptoms 743 

causes 748 

diagnosis 748 

prognosis 749 

morbid anatomy and pathology 749 

treatment 751 

Centrum ovale, lesions of. 362 

Cerebellar diseases. 348 

haemorrhages '. . . 353 

symptomatology of 348 

Cerebellar peduncles, lesions of. 357 

Cerebellum, atrophy of 354 

Cerebellum, lesions of. , 356 

Cerebellum, tumors of 351 

Cerebral abscess 265 

Cerebral anaemia 70 

symptoms 70 

causes 73 

diagnosis 75 

Cerebral anaemia, prognosis 75 

morbid anatomy 76 

pathology 76 

treatment 77 

Cerebral anaemia, partial 132 

Cerebral arteries, embolism of 142 

Cerebral arteries, thrombosis of. 132 

Cerebral blood-vessels, obliteration of. . . 132 
Cerebral capillaries, embolism and throm- 
bosis of 154 

Cerebral and cerebellar peduncles, lesions 

of 347 

Cerebral congestion 32 

Cerebral congestion, active. 32 

Cerebral congestion, passive 53 

Cerebral haemorrhage 80 

symptoms 81 

causes 93 

diagnosis. ..., 96 

prognosis 100 

morbid anatomy 101 

pathology 105 

differential diagnosis Ill 

treatment 118 

Cerebral hyperaemia 33 

Cerebral meningeal haemorrhage 124 

symptoms 124 

causes 126 

diagnosis 127 

prognosis 127 

morbid anatomy and pathology 128 

treatment 130 

Cerebral meningitis, acute 212 



INDEX. 



927 



FAGE 

Cerebral meningitis, chronic 221 

Cerebral softening 161 

symptoms 161 

causes 168 

diagnosis 169 

prognosis I" 1 -* 

morbid anatomy 170 

pathology 172 

treatment 176 

Cerebral sclerosis, diffused 271 

Cerebral syphilis 325 

Cerebria 269 

Cerebritis 259 

Cerebro-spinal diseases 641 

Cervical hypertrophic pachymeningitis. . .417 

Cervical sympathetic, neuroses of 855 

Cervical sympathetic, pathology of. 851 

Cervico- brachial neuralgia 842 

Cervico-occipitaL neuralgia 841 

Chorea 710 

symptoms 710 

causes 716 

diagnosis 717 

prognosis 718 

morbid anatomy and pathology 71 S 

treatment 721 

Chronic alcoholism 896 

symptoms 897 

Chronic basilar meningitis 231 

symptoms 232 

causes 239 

diagnosis 240 

prognosis 240 

morbid anatomy 241 

pathology 243 

treatment 247 

Chronic cerebral abscess 265 

Chronic cerebral meningitis 221 

Chronic neuritis 817 

symptoms 817 

causes 818 

diagnosis 819 

prognosis 819 

morbid anatomy and pathology 819 

treatment 819 

Chronic spinal meningitis 414 

symptoms 414 

causes 415 

diagnosis 416 

prognosis 416 

morbid anatomy and pathology 416 

treatment 423 

Chronic verticalar meningitis . 221 

symptoms 221 

causes 226 

diagnosis 227 

prognosis 227 

morbid anatomy and pathology 228 



PAGE 

Chronic verticalar meningitis, treatment. 230 

Colic, lead 889 

Columns, anterior, inflammation of 548 

Columns of Goll, sclerosis of 597 

Columns, lateral, and gray matter, in- 
flammation of 556 

Columns, lateral, inflammation of. 549 

Columns of Turck 548 

Congestion, cerebral 32 

Congestion, neural 804 

Congestion, spinal 365 

Convulsive tremor 693 

history and symptoms 698 

causes 706 

diagnosis 707 

prognosis 707 

morbid anatomy and pathology 707 

treatment 709 

Corpora quadrigemina, lesions of 360 

Corpora striata, lesions of 341, 361 

Cortex cerebri, lesions of. 363 

Cortical paralysis 334 

Crossed paralysis 115 

Crura cerebri, lesions of . 347 

Crural neuralgia 843 

Cutaneous nerves, anaesthesia of 834 

Diffused cerebral sclerosis 271 

symptoms 271 

causes 279 

diagnosis 279 

Diffused cerebral sclerosis, prognosis. . . . 280 

morbid anatomy 280 

pathology 281 

treatment 281 

Diseases of peripheral nervous system. . 803 

Diseases of the sympathetic nervous sys- 
tem 851 

Disseminated inflammation of the spinal 

cord 599 

symptoms 599 

causes 601 

diagnosis 602 

prognosis 602 

morbid anatomy and pathology 602 

treatment 605 

Dorso-intercostal neuralgia 842 

Dura mater, pachymeningitis and hsema- 

toma of 130 

Ecstasy 752 

symptoms 752 

causes 762 

treatment 762 

Electrical apparatus 19 

Electrical reactions 28 

Embolism of cerebral arteries 142 

symptoms 142 



928 



INDEX. 



PAGE 

Embolism of cerebral arteries, causes. . . . 145 

diagnosis 145 

prognosis 147 

morbid anatomy and pathology 147 

treatment 149 

Embolism of cerebral capillaries 154 

Embolism, flit 157 

Embolism, pigment 355 

Encephalitis, suppurative 259 

Epilepsy 663 

symptoms 663 

causes 678 

diagnosis 680 

prognosis 681 

morbid anatomy 681 

pathology 683 

treatment 692 

Exophthalmic goitre 789 

symptoms 789 

causes 795 

diagnosis 795 

prognosis 796 

morbid anatomy and pathology 796 

treatment 799 

Facial atrophy, progressive 519 

Facial paralysis . 821 

symptoms 821 

causes 825 

diagnosis 825 

prognosis 825 

morbid anatomy and pathology 826 

treatment 826 

Facial spasm 831 

symptoms 831 

causes 831 

diagnosis 832 

prognosis 832 

morbid anatomy and pathology 832 

treatment 832 

Fat embolism 157 

Festination 288 

Fifth pair, anaesthesia of 837 

Fifth pair of nerves, neuralgia of. . , 839 

General acute myelitis 429 

Glosso-labio-laryngeal paralysis 478 

symptoms 479 

causes 485 

diagnosis 485 

prognosis 486 

morbid anatomy and pathology 487 

treatment ' 494 

Goll, sclerosis of columns of. 597 

Haematoma of the dura mater 130 

symptoms 130 

causes 130 



PAGE 

Hsematoma of the dura mater, diagnosis. 130 

prognosis 131 

morbid anatomy and pathology 131 

treatment 132 

Haemorrhage, cerebellar. 353 

Haemorrhage, cerebral 80 

Haemorrhage, cerebral meningeal 124 

Haemorrhage, spinal meningeal 463 

Haemorrhage, spinal 406 

Haemorrhage, ventricular 343 

Hemianopsia 345 

Hemicrania 855 

Hemisphere, paralysis from central le- 
sions of 338 

Hydrargysm 921 

symptoms 921 

causes 922 

diagnosis 922 

prognosis 922 

morbid anatomy and pathology 922 

treatment 923 

Hydrophobia. . . .' 641 

symptoms 641 

causes 648 

diagnosis 651 

prognosis 653 

morbid anatomy 654 

pathology 659 

treatment 661 

Hyperaesthesia, lead 890 

Hyperesthesia, neural 838 

Hysteria. 727 

symptoms 727 

causes 736 

diagnosis 737 

prognosis 737 

Hysteria, morbid anatomy and pathology 738 

treatment 739 

Hystero- epilepsy 763 

symptoms 763 

causes 769 

diagnosis 769 

prognosis 769 

morbid anatomy and pathology 769 

treatment ' 769 

Hysteroid affections 742 

Infantile spinal paralysis 438 

symptoms. 439 

causes 442 

diagnosis • . , 442 

prognosis 443 

morbid anatomy 443 

pathology 452 

treatment 454 

Inflammation of anterior columns 548 

Inflammation of anterior tract of gray 
matter 437 



INDEX. 



929 



PAGE 

Inflammation of anterior and posterior 

tracts of gray matter 534 

Inflammation of columns of Goll 597 

Inflammation of lateral pyramidal tracts 549 

Inflammation of motor cells 478 

Inflammation of motor and trophic cells . 438 

Inflammation of the posterior columns. . 567 
Inflammation of posterior tract of gray 

matter 532 

Inflammation of the spinal cord 429 

Inflammation of trophic cells 494 

Intra-spinal haemorrhage and pachymen- 
ingitis 417 

Landry's paralysis 868 

Lateral columns and anterior gray mat- 
ter, inflammation of 556 

Lateral pyramidal tracts, inflammation of 549 

Lead anaesthesia 890 

Lead-colic 889 

symptoms 889 

Lead encephalopathy 886 

Lead hyperaesthesia 890 

causes 891 

diagnosis 892 

prognosis — 893 

morbid anatomy and pathology 893 

treatment 895 

Lead-paralysis 888 

Lesions of the centrum ovale 332 

Lesions of the cerebral and cerebellar pe- 
duncles 347 

Lesions of the corpora striata 341, 361 

Lesions of the cortex cerebri 363 

Lesions of the medulla oblongata 358 

Lesions of the optic thalamus 360 

Lesions of the pons Varolii 358 

Lesions of optic tracts 345 

Lesions of tubercula quadrigemina . . 343, 360 

Locomotor ataxia 567 

Lumbo-abdominal neuralgia 843 

Medulla oblongata, lesions of 358 

Meningitis, acute cerebral .. 212 

chronic basilar 231 

Meningitis, chronic cerebral ... 221 

chronic verticular 221 

rheumatic ,. 214 

senile 215 

spinal 413 

tubercular cerebral 251 

Migraine 855 

Motor cells, inflammation of 478 

Motor and trophic cells, inflammation of. 438 

Multiple cerebro-spinal sclerosis 770 

symptoms 770 

causes 780 

diagnosis 780 



PAGE 

Multiple cerebro-spinal sclerosis, prog- 
nosis 781 

morbid anatomy and pathology 781 

treatment 781 

Multiple neuritis 815 

symptoms 815 

causes 816 

diagnosis 816 

prognosis 816 

morbid anatomy and pathology 817 

treatment 817 

Multiple spinal sclerosis 599 

Muscular atrophy, progressive 495 

Muscular sense 287 

Myelitis, acute general 429 

acute 429 

Myelitis, acute partial 431 

Myotonia congenita 880 

symptoms 880 

causes 881 

diagnosis 881 

prognosis 881 

morbid anatomy and pathology 882 

treatment 882 

Myxoedeina 870 

symptoms 871 

causes 876 

diagnosis 876 

prognosis 877 

morbid anatomy and pathology 877 « 

treatment 878 

Nerves, tumors of 820 

Nervous system, toxic diseases of 886 

Neural anaesthesia 834 

atrophy 817 

congestion 804 

hyperaesthesia 838 

sclerosis 817 

spasm 831 

paralysis 821 

Neuralgia 838 

cervico-brachial 842 

symptoms 842 

causes 842 

diagnosis 842 

prognosis 842 

Neuralgia, cervico-occipital 841 

symptoms 841 

causes 841 

diagnosis 841 

prognosis 841 

Neuralgia, crural , 843 

dorso-intercostal 842 

Neuralgia of fifth pair of nerves 639 

Neuralgia of fifth pair of nerves, symp- 
toms 839 

causes 840 



930 



INDEX. 



PAGE 

Neuralgia of fifth pair of nerves, diagnosis 841 

prognosis 841 

lumbo-abdominal. 843 

treatment of. 843 

Neuritis, acute 806 

chronic 817 

multiple 815 

Non-inflammatory softening of the spinal 

cord 611 

symptoms 611 

causes 614 

diagnosis 614 

prognosis 614 

morbid anatomy and pathology 615 

treatment 615 

Nothnagel's symptomatology 355 

Obliteration of cerebral blood-vessels. . . 132 

Optic thalamus, lesions of 341, 360 

Optic tracts, lesions of 345 

Organic infantile paralysis 438 

Pachymeningitis 130 

cervical 417 

Paralysis, acute ascending 868 

Paralysis agitans 282 

symptoms 283 

causes 289 

diagnosis 290 

prognosis 291 

morbid anatomy and pathology 291 

treatment 293 

Paralysis, anapeiratic 784 

Paralysis consecutive to central lesions of 

the hemispheres 338 

Paralysis, cortical 334 

Paralysis, facial 821 

Paralysis, infantile spinal 438 

Paralysis, glosso-labio-laryngeal 478 

Paralysis, Landry's 868 

Paralysis, neural 821 

Paralysis of radial nerve 830 

Paralysis of sixth nerve 830 

Paralysis of third nerve 828 

Paralysis, pseudo-hypertrophic 629 

Paralysis, spinal, of adults 458 

Paralysis, lead 888 

symptoms 888 

Paramyoclonus multiplex 698 

Paraphasia 202 

Paretic tremor 782 

symptoms 782 

causes 782 

diagnosis 783 

prognosis 783 

morbid anatomy and pathology 783 

treatment 784 

Partial cerebral ansemia 132 



PAGE 

Passive cerebral congestion 53 

symptoms 53 

causes 56 

diagnosis 58 

Passive cerebral congestion, prognosis. . 60 

morbid anatomy 61 

pathology 62 

treatment 64 

Pathology of abdominal sympathetic 865 

Pathology of cervical sympathetic 851 

Pathology of thoracic sympathetic 863 

Peripheral nervous system, diseases of. . 803 

Pigment, embolism 155 

Plumbism 886 

symptoms 886 

Polio-myelitis anterior 438 

Pons Varolii, lesions of 358 

Posterior columns, sclerosis of. 567 

Posterior tract of gray matter, inflamma- 
tion of 532 

Primary symmetrical lateral sclerosis. . . 549 

symptoms 549 

causes 552 

diagnosis 552 

prognosis 552 

morbid anatomy and pathology, .... 552 

treatment 555 

Progressive facial atrophy 519 

symptoms 519 

causes 524 

diagnosis 524 

prognosis 524 

morbid anatomy and pathology 525 

treatment 531 

Progressive locomotor ataxia 567 

symptoms 567 

causes 579 

diagnosis 579 

prognosis 580 

morbid anatomy 580 

pathology 585 

treatment. 591 

Progressive muscular atrophy 495 

symptoms 495 

causes \ 501 

diagnosis 509 

prognosis 510 

morbid anatomy and pathology 510 

treatment 517 

Pseudo-hypertrophic paralysis 629 

symptoms 630 

causes 636 

diagnosis 636 

prognosis 637 

morbid anatomy and pathology 637 

treatment 639 

Eadial nerve, paralysis of. 830 



INDEX. 



931 



PAGE 

Kaynaud's disease 882 

Keactions of defeneration 28 

Kheuinatic meningitis 214 

Sciatica 809 

symptoms 809 

causes 810 

diagnosis 811 

Sciatica, prognosis 811 

morbid anatomy and pathology 811 

treatment 812 

Sclerosis, amyotrophic, lateral spinal 556 

Sclerosis of anterior pyramidal tract. .... 548 

Sclerosis, diffused cerebral 271 

Sclerosis of lateral pyramidal tract 549 

Sclerosis, multiple cerebro-spinal 776 

Sclerosis, multiple spinal 529 

Sclerosis, neural 817 

Sclerosis, primary symmetrical lateral. . . 549 

Sclerosis of posterior columns 567 

Secondary degeneration of spinal cord . . 605 

symptoms 608 

causes 608 

diagnosis 609 

prognosis 609 

morbid anatomy and pathology 609 

treatment 610 

Senile meningitis 215 

Sixth nerve, paralysis of 830 

Softening, cerebral 161 

Softening, non-inflammatory, of spinal 

cord 611 

Spasm, facial 831 

neural 831 

Spastic spinal paralysis 549 

Spinal anaemia 373 

Spinal congestion 365 

symptoms 365 

causes 367 

diagnosis 369 

prognosis 370 

morbid anatomy 370 

pathology 370 

treatment 371 

Spinal cord, anaemia of posterior columns 

of. , 374 

diseases of. 365 

disseminated inflammation of. 599 

inflammation of 429 

non-inflammatory softening of 611 

secondary degeneration of. 605 

syphilis of 623 

tumors of 61 6 

Spinal haemorrhage 406 

symptoms 406 

causes 407 

diagnosis 407 

prognosis 409 



PAGE 

Spinal haemorrhage, morbid anatomy and 

pathology 411 

treatment 412 

Spinal irritation 374 

history 374 

symptoms 382 

causes 387 

morbid anatomy and pathology 388 

diagnosis 390 

prognosis 391 

Spinal irritation, treatment 392 

Spinal meningitis 413 

Spinal paralysis, infantile 438 

Spinal paralysis of adults 458 

symptoms 460 

causes 468 

diagnosis 469 

prognosis 471 

morbid anatomy and pathology 471 

treatment 473 

Suppurative encephalitis 259 

symptoms 259 

causes 262 

diagnosis 263 

prognosis 263 

morbid anatomy and pathology 264 

treatment 268 

Symmetrical gangrene of the extremities. 882 

symptoms 883 

morbid anatomy and pathology 883 

treatment 885 

Sympathetic nervous system, diseases of. 851 

Symptomatology of cerebellar lesions 348 

Symptomatology of cerebral lesions 334 

Syphilis, cerebral 325 

Syphilis of the peripheral nervous sys- 
tem 849 

Syphilis of the spinal cord and its mem- 
branes 623 

Syringomyelia 626 

symptoms 626 

causes 627 

diagnosis 627 

prognosis 628 

morbid anatomy and pathology 628 

treatment 629 

Tabes dorsalis 567 

Tetanus 534 

symptoms 535 

causes 537 

diagnosis 539 

prognosis 540 

morbid anatomy and pathology 540 

treatment 545 

Third nerve, paralysis of 828 

symptoms 828 

causes 829 



932 



INDEX. 



PAGE 

Third nerve, diagnosis 829 

prognosis 829 

morbid anatomy and pathology 830 

treatment 830 

Thomsen's disease 880 

Thoracic sympathetic, pathology of 863 

Thrombosis of cerebral arteries 132 

symptoms 133 

causes 136 

diagnosis 137 

Thrombosis of cerebral arteries, prog- 
nosis 137 

morbid anatomy and pathology 137 

treatment 141 

cerebral capillaries „ 159 

Thrombosis of cerebral veins and sinuses. 149 

symptoms , 149 

causes 153 

prognosis 153 

diagnosis 154 

morbid anatomy and pathology 154 

treatment 154 

Torticollis 832 

causes 833 

diagnosis. 833 

prognosis 833 

morbid anatomy and pathology 833 

treatment 833 

Toxic diseases of the nervous system. . . . 886 

Treatment of neuralgia 843 

Tremor, convulsive 698 



PAGE 

Trophic cells, inflammation of. 494 

Tubercula quadrigemina, lesions of.. .343, 360 

Tubercular cerebral meningitis 251 

symptoms 251 

causes '. 255 

diagnosis 256 

prognosis 256 

morbid anatomy and pathology 257 

treatment 258 

Tumors of the brain 296 

symptoms 296 

causes 304 

diagnosis 305 

prognosis 307 

morbid anatomy and pathology 307 

treatment 312 

Tumors of cerebellum 351 

Tumors of nerves 820 

Tumors of spinal cord 616 

symptoms 616 

causes 621 

diagnosis 621 

prognosis 622 

morbid anatomy and pathology 622 

treatment 622 

Turck, columns of 548 

Veins and sinuses, cerebral, thrombosis of 149 

"Word-blindness 201 

Word-deafness 201 



THE END. 



March, 1891. 



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